77c Abstract Book

ANESTHESIA
&
ANALGESIA
Journal of the International Anesthesia Research Society, the Society of Cardiovascular Anesthesiologists,
the Society for Pediatric Anesthesia, the Society for Ambulatory Anesthesia,
the International Society for Anaesthetic Pharmacology, and the Society for Technology in Anesthesia
Abstracts of Posters
Presented at the
International Anesthesia Research Society
77th Clinical and Scientific Congress
New Orleans, LA
March 21-25, 2003
This Supplement will Appear On-Line Only
ISSN 0003-2999 Volume 96, Number 2S, February 2003 Supplement to Anesthesia & Analgesia
ANESTHESIA & ANALGESIA
IARS SCA SPA SAMBA ISAP STA

Editor-in-Chief EDITORIAL BOARD
Ronald D. Miller
San Francisco, California John Butterworth Hans-Joachim Priebe
Associate Editor-in-Chief Winston-Salem, North Carolina Freiburg, Germany
Cardiovascular Anesthesia Neal Cohen Richard C. Prielipp
Kenneth J. Tuman San Francisco, California Winston-Salem, North Carolina
Chicago, Illinois John C. Rowlingson
Managing Editor Pierre Coriat
Paris, France Charlottesville, Virginia
King C. Kryger
kkryger@yahoo.com François Donati Koh Shingu
Production Editor Montréal, Québec, Canada Osaka, Japan
Nancy Lynly Thomas J. Gal Peter Douglas Slinger
nlynly@pacbell.net Charlottesville, Virginia Toronto, Ontario, Canada
Editorial Systems Manager Tony Gin Graham Smith
Jeanette Esau Shatin, Hong Kong, China Leicester, England
aaeditor@pacbell.net
Editorial Assistant Jonas S. Johansson Christoph Stein
Darlene Ishigo Philadelphia, Pennsylvania Berlin, Germany
dishigo@pacbell.net Sten Lindahl Margaret M. Tarpey
Stockholm, Sweden Birmingham, Alabama
Guest Editors
Elliot Bennett-Guerrero
James Caldwell SECTION EDITORS
Mark Chaney Ambulatory Anesthesia Pain Medicine
Edmond I Eger, II Paul F. White Michael J. Cousins
Peter Glass Dallas, Texas Sydney, Australia
Eugene Hessel, II
Charles Hogue Anesthetic Pharmacology
Terese Horlocker James G. Bovill Pediatric Anesthesia
Jeffrey Katz Leiden, The Netherlands William J. Greeley
Aaron Kopman Philadelphia, Pennsylvania
Critical Care and Trauma
Tom Krejcie
Harry Lemmens
Jukka Takala Regional Anesthesia
Bern, Switzerland Denise J. Wedel
Spencer Liu
Martin London Economics, Education, and Rochester, Minnesota
Robert McCarthy Health Systems Research
Christopher O’Connor Ronald D. Miller Book and Multimedia Reviews
Peter Sebel San Francisco, California Norig Ellison
Mark Stafford-Smith Neurosurgical Anesthesia Philadelphia, Pennsylvania
Greg Stratmann David S. Warner
Daniel Thys Durham, North Carolina Technology, Computing, and
Joyce Wahr Simulation
Charles Whitten Obstetric Anesthesia
Annie Woodhouse David J. Birnbach Steven J. Barker
Spencer Yost Miami, Florida Tucson, Arizona
Paul Zanaboni
Manuscripts and editorial correspondence should be addressed to Ronald D. Miller, MD, Editor-in-Chief, ANESTHESIA & ANALGESIA, The Hearst Building,
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Books and multimedia for review should be sent directly to Norig Ellison, MD, Book Review Editor, Department of Anesthesia, University of Pennsylvania,
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ANESTHESIA & ANALGESIA®
Journal of the International Anesthesia Research Society®, the Society of Cardiovascular Anesthesiologists, the
Society for Pediatric Anesthesia, the Society for Ambulatory Anesthesia,
Abstracts of Posters
Presented at the
International Anesthesia Research Society
77th Clinical and Scientific Congress
New Orleans, LA
March 21-25, 2003
Abstracts (by category):
Ambulatory Anesthesia S-1 – S-13
Cardiothoracic and Vascular - Basic Science S-14 – S-36
Cardiothoracic and Vascular - Clinical S-37 – S-61
Critical Care and Trauma S-62 – S-82
Economics; Education and Patient Safety S-83 – S-115
Equipment/Monitoring S-116 – S-164
Neuroanesthesia S-165 – S-174
Obstetric Anesthesia S-175 – S-187
Pain - Basic Science S-188 – S-194
Pain - Clinical S-195 – S-218
Pediatric Anesthesia S-219 – S-227
Pharmacology - Basic Science S-228 – S-254
Pharmacology - Clinical S-255 – S-276
Regional S-277 – S-293
Author Index: S-294 – S-303
Subject Index: S-304 – S-313
Authors submitting abstracts have certified that if human research is reported, approval by an institutional human research committee
has been obtained, or if animal research is reported, the usual standards and guidelines for animal care have been followed. Material pub-
lished in this supplement has not undergone review by the Editorial Board of Anesthesia and Analgesia. Any of the abstracts in this sup-
plement may have been transmitted by the author to IARS in various forms of electronic medium. IARS has used its best efforts to receive
and format electronic submissions for publication in this supplement but has not reviewed each abstract for the purpose of textual error
correction and is not liable in any way for any formatting, textual or grammatical error or inaccuracy.
©2003 by the International Anesthesia Research Society

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IARS 77th Clinical and Scientific Congress
Abstract Presenter Presentation Schedule
(S-48) Fortier, J.D., Sunday 8:00
Ambulatory Anesthesia (S-49) Isetta, C.J., Sunday 8:00
(S-1) Kranke, P., Saturday 8:00 (S-50) Xia, Z., Sunday 8:00
(S-2) Ma, H., Saturday 8:00 (S-51) Xia, Z., Sunday 8:00
(S-3) Van Den Kerkhof, E.G., Saturday 8:00 (S-52) Ansley, D.M., Sunday 8:00
(S-4) Vila Jr., H., Saturday 8:00 (S-53) Gramlich, L., Tuesday 8:00
(S-5) Tang, J., Saturday 8:00 (S-54) Royston, D., Tuesday 8:00
(S-6) El-Hadidy, A., Saturday 8:00 (S-55) Takagi, E.N., Tuesday 8:00
(S-7) Kohjitani, A., Saturday 8:00 (S-56) Ramachandran, S., Tuesday 8:00
(S-8) Recart, A., Saturday 8:00 (S-57) Welsby, I.J., Tuesday 8:00
(S-9) Recart, A., Saturday 8:00 (S-58) Donahue, B.S., Tuesday 8:00
(S-10) Rafizadeh, M., Saturday 8:00 (S-59) Yoshikawa, D., Tuesday 8:00
(S-11) Ates, Y., Saturday 8:00 (S-60) Ishida, K., Tuesday 8:00
(S-12) Fang, Z., Saturday 8:00 (S-61) Kawahara, F., Tuesday 8:00
(S-13) Stice-Beredino, L.L., Saturday 8:00

Cardiovascular Anesthesia – Basic Science (S-62) Pandit, J.J., Monday 8:00
(S-14) Kevin, L.G., Monday 8:00 (S-63) Fan, Q., Monday 8:00
(S-15) de Klaver, M.M., Monday 8:00 (S-64) Fan, Q., Monday 8:00
(S-16) Novalija, E., Monday 8:00 (S-65) Fan, Q., Monday 8:00
(S-17) Dworschak, M., Monday 8:00 (S-66) Joshi, G.P., Monday 8:00
(S-18) Kevin, L.G., Monday 8:00 (S-67) Ogunnaike, B., Monday 8:00
(S-19) Mersmann, J., Monday 8:00 (S-68) Toma, G., Monday 8:00
(S-20) Hara, T., Monday 8:00 (S-69) Ghori, K., Monday 8:00
(S-21) Hoffman, W.E., Monday 8:00 (S-70) Menzebach, A., Monday 8:00
(S-22) Schwinn, D.A., Monday 8:00 (S-71) Yuan, S., Monday 8:00
(S-23) Westphal, M., Monday 8:00 (S-72) Johnson, C., Monday 8:00
(S-24) Fujisawa, T., Monday 8:00 (S-73) Bagchi, A., Monday 8:00
(S-25) Sumita, S., Monday 8:00 (S-74) Oku, S., Monday 8:00
(S-26) Hare, G.T., Monday 8:00 (S-75) Urban, M.K., Monday 8:00
(S-28) Yoshimura, M., Monday 8:00 (S-76) Jahr, J.S., Monday 8:00
(S-29) Pandit, J.J., Monday 8:00 (S-77) Jahr, J.S., Monday 8:00
(S-30) Gust, A.M., Monday 8:00 (S-78) Westphal, M., Monday 8:00
(S-31) Urdaneta, F., Monday 8:00 (S-79) McGlinch, B.P., Monday 8:00
(S-32) Hu, G., Monday 8:00 (S-80) Scher, C.S., Monday 8:00
(S-33) Shiga, T., Monday 8:00 (S-81) Tungpalan, L., Monday 8:00
(S-34) Tse, J., Monday 8:00 (S-82) Nakamura, T., Monday 8:00
(S-35) Yang, H., Monday 8:00
(S-36) Jahn, U.R., Monday 8:00
Economics; Education and Patient Care
(S-83) Anderson, K.J., Saturday 8:00
Cardiovascular Anesthesia - Clinical (S-84) Kinsella, J., Saturday 8:00
(S-37) Girgenti, G.T., Sunday 8:00 (S-85) Maroof, M., Saturday 8:00
(S-38) Park, K.W., Sunday 8:00 (S-86) Bilgin, H., Saturday 8:00
(S-39) Fukusaki, M., Sunday 8:00 (S-87) Hilmi, I.A., Saturday 8:00
(S-40) Aggarwal, S., Sunday 8:00 (S-88) Greenfield, M.V., Saturday 8:00
(S-41) Akhtar, S., Sunday 8:00 (S-89) Kovac, A., Saturday 8:00
(S-42) Pandit, J.J., Sunday 8:00 (S-90) Minogue, S.C., Saturday 8:00
(S-43) Pandit, J.J., Sunday 8:00 (S-91) Niemann, C.U., Saturday 8:00
(S-44) Praetel, C., Sunday 8:00 (S-92) Lew, M.W., Saturday 8:00
(S-45) Bar-Yosef, S., Sunday 8:00 (S-93) Cattano, D., Saturday 8:00
(S-46) Riedel, B.J., Sunday 8:00 (S-94) Havidich, J.E., Saturday 8:00
(S-47) Fortier, J.D., Sunday 8:00 (S-95) Turner, C.R., Saturday 8:00
(S-96) Cohen, I.T., Saturday 8:00 (S-147) Soto, R.G., Monday 8:00
(S-97) Agarwala, A.V., Saturday 8:00 (S-148) Lirk, P., Monday 8:00
(S-98) Cook, R.I., Saturday 8:00 (S-149) Tang, Y., Monday 8:00
(S-99) Weinger, M.B., Saturday 8:00 (S-150) Schultz, J.R., Monday 8:00
(S-100) Sharma, R., Saturday 8:00 (S-151) Uchida, I., Monday 8:00
(S-101) Seiden, S., Saturday 8:00 (S-152) Verghese, S.T., Monday 8:00
(S-102) Ramachandran, S., Saturday 8:00 (S-153) Horowitz, P.E., Monday 8:00
(S-103) Vohra, P., Saturday 8:00 (S-154) Lewis, K., Monday 8:00
(S-104) Souders, J.E., Saturday 8:00 (S-155) Kawasaki, J., Monday 8:00
(S-105) Weaver, J.M., Saturday 8:00 (S-156) Chen, F., Monday 8:00
(S-106) Strum, D.P., Saturday 8:00 (S-157) Hagberg, C.A., Monday 8:00
(S-107) Strum, D.P., Saturday 8:00 (S-158) Kumar, R., Monday 8:00
(S-108) Greenfield, M.V., Saturday 8:00 (S-159) Bolis, R.S., Monday 8:00
(S-109) Orkin, F.K., Saturday 8:00 (S-160) Paulsen, A., Monday 8:00
(S-110) Singbartl, G., Saturday 8:00 (S-161) Chu, L.F., Monday 8:00
(S-111) Singbartl, G., Saturday 8:00 (S-162) Kling, J.C., Monday 8:00
(S-112) Singbartl, G., Saturday 8:00 (S-163) Yilmazlar, A., Monday 8:00
(S-113) Singbartl, G., Saturday 8:00 (S-164) Yilmazlar, A., Monday 8:00
(S-114) Knuepfer, P.E., Saturday 8:00
(S-115) Nakatsuka, M., Saturday 8:00
Neuroanesthesia
(S-165) Kimotsuki, H., Saturday 8:00
Equipment/Monitoring (S-166) Bekker, A., Saturday 8:00
(S-116) Sanderson, I.C., Sunday 8:00 (S-167) Homi, H.M., Saturday 8:00
(S-117) Sanderson, I.C., Sunday 8:00 (S-168) Brock-Utne, J.G., Saturday 8:00
(S-118) Brock-Utne, J.G., Sunday 8:00 (S-169) Ghori, K., Saturday 8:00
(S-119) Rosenbaum, A., Sunday 8:00 (S-170) Paisansathan, C., Saturday 8:00
(S-120) Rosenbaum, A., Sunday 8:00 (S-171) Kitano, T., Saturday 8:00
(S-121) Hamza, M.A., Sunday 8:00 (S-172) Verplancke, T., Saturday 8:00
(S-122) Bryan, Y., Sunday 8:00 (S-173) Pivalizza, E.G., Saturday 8:00
(S-123) Ryu, H., Sunday 8:00 (S-174) Giffard, R.G., Sunday 3:00
(S-124) Robinson, M.B., Sunday 8:00
(S-125) El-Fandy, G., Sunday 8:00
(S-126) Nagata, O., Sunday 8:00 Obstetric Anesthesia
(S-127) Recart, A., Sunday 8:00 (S-175) Chin, K., Sunday 8:00
(S-128) Recart, A., Sunday 8:00 (S-176) Uchida, J., Sunday 8:00
(S-129) Gasanova, I., Sunday 8:00 (S-177) Terui, K., Sunday 8:00
(S-130) Nishiyama, T., Sunday 8:00 (S-178) Finegold, H., Sunday 8:00
(S-131) Nishihara, F., Sunday 8:00 (S-179) Denenberg, H., Sunday 8:00
(S-132) Manyam, S.C., Sunday 8:00 (S-180) Megally, M., Sunday 8:00
(S-133) Lennmarken, C., Sunday 8:00 (S-181) Bullough, A.S., Sunday 8:00
(S-134) Deal, E.R., Sunday 8:00 (S-182) Gonzalez, R., Sunday 8:00
(S-135) Viertiö-Oja, H., Sunday 8:00 (S-183) Cohen, S., Sunday 8:00
(S-136) Hemmerling, T.M., Sunday 8:00 (S-184) Rinne, T., Sunday 8:00
(S-137) Martin, G., Monday 8:00 (S-185) Chiu, J., Sunday 8:00
(S-138) Roy, R.J., Monday 8:00 (S-186) Waibel, H.A., Sunday 8:00
(S-139) Marcus, R.L., Monday 8:00 (S-187) Ramanathan, S., Sunday 8:00
(S-140) Lichtenthal, P.R., Monday 8:00
(S-141) Yem, J.S., Monday 8:00
(S-142) Diemunsch, P., Monday 8:00
(S-143) Demirkiran, O., Monday 8:00
(S-144) Ito, S., Monday 8:00
(S-145) Aguilar, G., Monday 8:00
(S-146) Demirkiran, O., Monday 8:00
Pain – Basic Sciences Pharmacology - Basic Science

(S-188) Lu, Y., Sunday 8:00 (S-228) Fields, A.M., Sunday 8:00
(S-189) Kroin, J.S., Sunday 8:00 (S-229) Fields, A.M., Sunday 8:00
(S-190) Kroin, J.S., Sunday 8:00 (S-230) Fields, A.M., Sunday 8:00
(S-191) Buvanendran, A., Sunday 8:00 (S-231) Fields, A.M., Sunday 8:00
(S-192) Nishiyama, T., Sunday 8:00 (S-232) Yuan, C., Sunday 8:00
(S-193) Michael, R., Sunday 8:00 (S-233) Mitsuyo, T., Sunday 8:00
(S-194) Schumacher, M.A., Sunday 3:00 (S-234) Nakamura, S., Sunday 8:00
(S-235) Xia, Z., Sunday 8:00
(S-236) Lee, C., Sunday 8:00
Pain - Clinical (S-237) Gyermek, L., Sunday 8:00
(S-195) Recart, A., Saturday 8:00 (S-238) Lee, Y., Sunday 8:00
(S-196) Munir, M.A., Saturday 8:00 (S-239) Lirk, P., Sunday 8:00
(S-197) Aoki, T., Saturday 8:00 (S-240) Shibata, O., Sunday 8:00
(S-198) Takada, M., Saturday 8:00 (S-241) Girard, T., Sunday 8:00
(S-199) Mamiya, K., Saturday 8:00 (S-242) Hahn, R.G., Sunday 8:00
(S-200) Chaudhuri, K., Saturday 8:00 (S-243) Michael, R., Sunday 8:00
(S-201) Miguel, R.V., Saturday 8:00 (S-244) Uchida, I., Tuesday 8:00
(S-202) Kopf, A., Saturday 8:00 (S-245) Veselis, R., Tuesday 8:00
(S-203) Buvanendran, A., Saturday 8:00 (S-246) Pentyala, S., Tuesday 8:00
(S-204) Blum, S.L., Saturday 8:00 (S-247) Breukelmann, D., Tuesday 8:00
(S-205) Coloma, M., Saturday 8:00 (S-248) Bar-Yosef, S., Tuesday 8:00
(S-206) Urban, M.K., Saturday 8:00 (S-249) Herroeder, S., Tuesday 8:00
(S-207) Domsky, R., Saturday 8:00 (S-250) Herroeder, S., Tuesday 8:00
(S-208) Khaleghi, B., Saturday 8:00 (S-251) Landrum, A.L., Tuesday 8:00
(S-209) Gratz, I., Saturday 8:00 (S-252) Ueta, K., Tuesday 8:00
(S-210) Ishikawa, A., Saturday 8:00 (S-253) Kariya, N., Tuesday 8:00
(S-211) She, S., Saturday 8:00 (S-254) Hollmann, M.W., Sunday 3:00
(S-212) Orkin, F.K., Saturday 8:00
(S-213) Panchal, S., Saturday 8:00
(S-214) Gonzalez, R., Saturday 8:00 Pharmacology - Clincal
(S-215) Yokoyama, M., Saturday 8:00 (S-255) Jorden, V., Saturday 8:00
(S-216) Lierz, P., Saturday 8:00 (S-256) Stapelfeldt, C.K., Saturday 8:00
(S-217) Hsu, E.S., Saturday 8:00 (S-257) Lewis, A., Saturday 8:00
(S-218) Buvanendran, A., Saturday 8:00 (S-258) Fang, Z., Saturday 8:00
(S-259) Taboada, M., Saturday 8:00
(S-260) Akhtar, S., Saturday 8:00
Pediatric Anesthesia (S-261) Sear, J.W., Saturday 8:00
(S-219) Verghese, S.T., Saturday 8:00 (S-262) Feierman, D.E., Saturday 8:00
(S-220) Verghese, S.T., Saturday 8:00 (S-263) Buvanendran, A., Saturday 8:00
(S-221) Mori, T., Saturday 8:00 (S-264) Sonoda, S., Saturday 8:00
(S-222) Kussman, B.D., Saturday 8:00 (S-265) Ates, Y., Saturday 8:00
(S-223) Splinter, W., Saturday 8:00 (S-266) Yazicioglu, H., Saturday 8:00
(S-224) Bryan, Y., Saturday 8:00 (S-267) Kodaka, M., Saturday 8:00
(S-225) Orkin, F.K., Saturday 8:00 (S-268) El-Orbany, M.I., Saturday 8:00
(S-226) Splinter, W.M., Saturday 8:00 (S-269) Hemmerling, T.M., Saturday 8:00
(S-227) Okamura, H., Saturday 8:00 (S-270) Demirkiran, O., Saturday 8:00
(S-271) Lu, Z., Saturday 8:00
(S-272) Acalovschi, I., Saturday 8:00
(S-273) Kovac, A., Saturday 8:00
(S-274) Rhee, K., Saturday 8:00
(S-275) Norton, J., Sunday 3:00
(S-276) Muir, S., Sunday 3:00
Regional
(S-277) Mohajer, P., Monday 8:00
(S-278) Adsumelli, R., Monday 8:00
(S-279) Pandit, J.J., Monday 8:00
(S-280) Parnass, S.M., Monday 8:00
(S-281) Gonzalez, R., Monday 8:00
(S-282) Grant, S.A., Monday 8:00
(S-283) Rao, J.H., Monday 8:00
(S-284) Kurup, V.J., Monday 8:00
(S-285) Smith, K.N., Monday 8:00
(S-286) Tcherven, N., Monday 8:00
(S-287) Yilmazlar, A., Monday 8:00
(S-288) Yilmazlar, A., Monday 8:00
(S-289) Gonzalez, R., Monday 8:00
(S-290) Ozdilmac, I., Monday 8:00
(S-291) Nakatani, T., Monday 8:00
(S-292) Orkin, F.K., Monday 8:00
(S-293) Williams, B.A., Sunday 3:00
Ambulatory
Anesthesia
Ambulatory Anesthesia
S-1 ABSTRACTS ANESTH ANALG
S-2 2003; 96; S-1–S-293
S-1
EFFICACY AND SAFETY OF TROPISETRONS- FOR THE who would have had PN had they all received a placebo (NNT=6.7;
PREVENTION OF POSTOPERATIVE NAUSEA AND 95%-CI: 4.8 – 11.1). Corresponding NNT for preventing PV and PONV
VOMITING: A QUANTITATIVE SYSTEMATIC REVIEW was 5.0 (95%-CI: 3.6 – 8.3) and 4.6 (95%-CI: 3.6 – 6.3), respectively.
(METAANALYSIS) Reporting of adverse effects was variable to a large extend between the
trials, as were the observed incidences of symptoms. For headache, for
AUTHORS: P. Kranke1, L. H. Eberhart2, C. C. Apfel1, A. M. Morin2, instance, analysis revealed that about 50 patients have to receive
N. Roewer1 tropisetron for one additional patient to suffer from headache that would
AFFILIATION: 1University of Wuerzburg, Wuerzburg, Germany, not occur had they all received a placebo. The use of tropisetron was not
2 associated with serious adverse effects.
University of Marburg, Marburg, Germany. CONCLUSION: Tropisetron safely reduced the incidence of emetic
INTRODUCTION: To estimate the efficacy and harm produced by symptoms. There is no clear evidence for a dose response between 2
tropisetron in the prevention of postoperative nausea and vomiting and 5 mg iv. For children a dose of 0.1 mg × kg-1 of body weight is
(PONV) we performed a quantitative systematic review of randomised effective. Oral application cannot be recommended so far due to lacking
controlled trials that investigated tropisetron versus placebo to prevent data.
postoperative nausea (PN) and vomiting (PV). REFERENCE: [1] Anesth Analg 2002; 95: 133-143
METHODS: Systematic search (MEDLINE, EMBASE, Cochrane-
Library, hand-searching, bibliographies, all languages, up to December
2001) for randomised comparisons of tropisetron with placebo in
surgical patients. Relevant outcomes were prevention of PN, PV,
PONV, rescue treatment and adverse effects. Combined data were
analysed using relative risk (RR) and number-needed-to-treat/harm
(NNT/NNH).
RESULTS: In 19 trials and 22 comparisons 1,012 patients received a
placebo and 1,267 patients tropisetron. In adults fixed intravenous doses
between 0.5 and 7 mg were administered (14 trials). In children variable
doses of 0.1 mg × kg-1 and 0.2 mg × kg-1 were used (4 trials). On trials
tested oral tropisetron (5 mg) in adults. We were unable to demonstrate
an apparent dose-response between fixed doses of 2 and 5 mg in adults,
therefore, pooled analyses (2 – 5 mg iv) are presented. The RR for PN,
PV and PONV with tropisetron was 0.72 (95%-CI: 0.62 – 0.83), 0.59
(95%-CI: 0.47 – 0.73) and 0.70 (95%-CI: 0.62 – 0.79), respectively. RR
for rescue treatment was 0.63 (95%-CI: 0.54 – 0.74). RR in children for
a variable dose between 0.1 and 0.2 mg × kg-1 was 0.49 (95%-CI: 0.38 –
0.63), 0.49 (95%-CI: 0.38 – 0.63) and 0.32 (95%-CI: 0.15 – 0.70), for
PV, PONV and rescue treatment, respectively. Restricting the analysis
to a predefined control event rate of 40-80% [1] revealed that about 6-7
patients need to be treated with tropisetron for one to prevent from PN
S-2
ROFECOXIB PREMEDICATION IMPROVES OUTCOME used during intraoperative period. The early recovery profiles with
AFTER OUTPATIENT INGUINAL HERNIORRHAPHY respect to the times to sitting up, tolerating oral fluids, standing up,
ambulating, “fitness” for discharge, and actual discharge were
AUTHORS: H. Ma1, J. Tang1, P. F. White2, R. H. Wender1, A. Zaentz1 significantly decreased in patients who received rofecoxib. Rofecoxib
AFFILIATION: 1Department of Anesthesiology, Cedars-Sinai also significantly reduced the requirements for rescue pain medication
Medical Center, Los Angeles, CA, 2Department of Anesthesiology, UT during the 24 h study period, and was more effective in controlling
Southwestern Medical Center at Dallas, Dallas, TX. postoperative pain without increasing side effects (e.g., bleeding,
nausea, vomiting).
INTRODUCTION: As a result of concerns regarding side effects CONCLUSION: Rofecoxib, 50 mg oral, was highly effective in
related to opioids, non-opioid analgesics are becoming increasingly improving pain management and the quality of recovery after outpatient
popular as part of a multimodal regimen to control pain after inguinal hernia repair surgery when administered preoperatively and on
ambulatory surgery. Rofecoxib, a COX-2 selective inhibitor, has been the first postoperative day without increasing intraoperative blood loss
shown to produce comparable analgesic effects to conventional or producing wound complications.
NSAIDs when administered for the treatment of acute pain. However, Hydro-
the analgesic effect of rofecoxib has not been extensively evaluated Sur- Tolerat-
Age Weight gery Orien- ing oral
Ambu- “Fit” Actual Qual- morphone Oral anal- Maximum Global
lating for dis- dis-ity of used
Blood Nausea
gesic pain dur- evaluation loss dur- and vom-
when administered for preemptive analgesia in the ambulatory setting. (yrs) (kg) time tation fluids
(min)
(min)
(min)
alone charge charge
(min) (min) (min)
recov- before dis- after dis- ing the of the study ing sur- iting
ery (n) charge(mg (n)
charge study medication gery
(ml) <24h (%)
Therefore, we designed this randomized, double-blinded, placebo- 45 73 41 10 56 99 106 127 16.4
)
0.13
period (n) (n)
6.2
controlled study to assess the analgesic efficacy of rofecoxib when Control ±
12
±
10
±
15
±
10
±
28
±
41
±
41
±
83
±
1.3
±
0.29
11
(1-33)
2
(1-3)
1
(0-3)
±
2.3
21
administered for premedication prior to ambulatory surgery. Rofecoxib

46
±
78
±
43
±
11
±
43
±
82
±
84
±
88
±
17.5
±
0.04
±
0 1 3
5.7
± 14
METHODS: 50 healthy outpatients undergoing inguinal hernia repair 15 14 22 11 17* 32* 32* 31* 1.0* 0.21
(0-20)* (0-3)* (1-4)*
2.1
with local anesthetic-based anesthesia techniques were randomly

assigned to one of two study groups (n=25/each): Control (Vitamin C),
and Rofecoxib (rofecoxib 50 mg). The first oral dose of the study
medication was administered 30 min before surgery and a second dose
of the same medication was taken the first morning after surgery. Verbal
pain scores were assessed at regular postoperative intervals, with
0=none, 1=mild, 2=moderate, and 3=severe. Recovery times, quality of
recovery (0-18), the need for rescue analgesics, maximum pain score
(0=none, 1=mild, 2=moderate, 3=severe), and postoperative side effects
were also recorded. A follow-up evaluation was performed via
telephone at 24 h after surgery to assess patient global evaluation of the
study medication (0=poor, 1=fair, 2=good, 3=very good, 4=excellent),
and the need for oral opioid-containing pain medication after discharge.
A p-value <0.05 was considered statistically significant. (* p<0.05 vs
Control).
RESULTS: The two study groups were comparable with respect to
demographic characteristics, duration of surgery, and anesthetic drugs
ANESTH ANALG ABSTRACTS S-3
2003; 96; S-1–S-293 S-4
S-3
VALIDATION OF AN ELECTRONIC VS A PAPER VERSION Group
N
Paper
180
HH
60
Tablet
60
Kiosk
60
OF THE SELF-COMPLETED PRE-ADMISSION ADULT Mean age 54.5 55.5 52.9 52.2
Male:female ratio 38:62 37:63 35:65 45:55
ANESTHETIC QUESTIONNAIRE Procedure (%)
25 23 22 20
Ophthalmology
16 15 17 20
AUTHORS: E. G. Van Den Kerkhof1, D. H. Goldstein1, W. C. Orthopaedics
General surgery 17 10 23 12
12 13 10 18
Blaine1, M. Rimmer2 Gynaecology
Ear/nose/throat/oral 13 15 10 10
4 8 3 5
AFFILIATION: 1Queen's University, Kingston, ON, Canada, Urology
Other 13 15 15 16
2
Kingston General Hospital, Kingston, ON, Canada. Mean % agreement** 94.0 94.0 94.5 94.5
Median time (sec)* 176 189 156 137
Patient survey:
INTRODUCTION: Recent advances in hand held and wireless Use computer weekly 78 55 79 78
computing technology has provided an opportunity to improve access to Easy to complete
Worry about computerized PAAQ loss
95
20
98
5
100
16
93
8
patient information at the point-of-care1. Studies show that electronic, Worry about paper PAAQ loss
Comfortable completing
24
51
23
98
23
98
28
97
patient-completed questionnaires are effective in preoperative Prefer paper 36 3 7 0
Prefer computer 11 59 65 68
evaluation2;3, however patient acceptance and questionnaire completion Prefer paper or computer 53 37 28 32
rates are highest when the computer used to administer the *Chi square = 14.5, P = 0.002; **F3,120 = 0.108, P = 0.96
HH = handheld computer; Kiosk = desktop computer with touch screen; PAAQ = Pre Admission Anesthetic
questionnaire does not resemble a traditional desktop computer2;4. The Questionnaire.
purpose of this study was to evaluate an electronic self-administered DISCUSSION: Touch screen computer technology is a valid, efficient
Pre-Admission Adult Anesthetic Questionnaire (PAAQ) with the platform for patient-administered PAAQ. Patients expressed comfort
existing paper questionnaire. using the technology. The majority of patients indicated they would
METHODS: This un-blinded randomized control trial was conducted prefer the computer PAAQ over the paper PAAQ in future pre operative
in February/March 2002 and included patients seen in the Pre- assessments. Further software development is required to integrate the
admission Assessment Clinic who had completed a PAAQ in the patient questionnaire with an electronic perioperative patient record.
surgeon's office. Patient consent and ethics approval were obtained. Further research is needed to examine the impact of handheld
Patients were randomized to PAAQ completion using paper, handheld computers on the doctor-patient encounter.
computer, touch screen desktop computer (Kiosk), or Tablet. Patients REFERENCES:
were then asked to complete a satisfaction survey. The main study 1. Can J Anaesth 49:749-54, 2002.
hypothesis was that the electronic version of the PAAQ was equivalent 2. Anesthesiology 75:394-400, 1991.
to the paper version, with respect to comprehensiveness, accuracy and 3. BMJ 324:1193-4, 2002.
time-to-completion. The sample size of 360 provided the ability to 4. Med Care 30:MS74-MS84, 1992.
detect a 20% difference in the completion rate and a difference in the
mean completion times of 0.53 standard deviations between the
electronic versus the paper arms, using a power of 90% and an alpha of
0.05.
RESULTS: Six patients refused to participate in the study. Of the
patients who were recruited, all completed the study. Two-thirds of the
patients were computer owners. Results are presented in the table.
S-4
FLORIDA OFFICE SURGERY AND AMBULATORY ambulatory surgery centers, respectively. The relative risks for injuries
SURGERY CENTER OUTCOMES FOLLOWING and deaths for office procedures vs. ambulatory surgery centers were
IMPLEMENTATION OF OFFICE REGULATIONS 12.4 (95% CI 9.5 to 16.2) and 11.8 (95% CI 5.8 to 24.1) respectively.
These calculations suggest that if all of the procedures done in offices
AUTHORS: H. Vila Jr.1, A. B. Cantor2, D. C. Mackey3, R. G. Soto4 instead were done in ambulatory surgery centers, 43 injuries and 6
AFFILIATION: 1Anesthesiology / Interdisciplinary Oncology, H. Lee deaths per year could be prevented. In the office deaths, 84 percent of
Moffitt Cancer Center and Research Institute / University of South the physicians were board certified and held active hospital privileges,
Florida, Tampa, FL, 2Biostatistics and Informatics Core, H. Lee Moffitt yet only 38 percent of the facilities were accredited and only 15 percent
had a dedicated physician anesthesia provider.
Cancer Center and Research Institute / University of South Florida,
DISCUSSION: The death rates for offices and ambulatory surgery
Tampa, FL, 3Anesthesiology / University of Florida, Gainesville, FL, centers found in this study are consistent with rates reported in previous
4
Anesthesiology / University of South Florida, Tampa, FL. studies which, in some cases, had depended upon voluntary
INTRODUCTION: In Florida, there has been a literal explosion in the reporting.3,4,5 There is a more than ten-fold greater mortality in offices
popularity of office surgery which, until recently, had little to no compared to ambulatory surgery centers despite Florida regulations.
regulation or oversight.1 In February 2000, the Florida Board of REFERENCES:
1. Fed Bull 2000;87:99-103.
Medicine enacted regulations for office surgery that included 2. Florida Board of Medicine Rule 64B8-9.009.www.doh.state.fl.us.
requirements for limitations of the procedure, accreditation of the office 3. Plast Reconstr Surg 2000;105:436-46.
facility, credentials of the surgeon, qualifications of anesthesia 4. JAMA 1993;70:1437-41.
personnel, and mandatory reporting of adverse incidents.2 5. Anesth Analg 1996;82:1273-83.
METHODS: This retrospective study reviews the first two years of
mandatory reporting of adverse incident data from Florida offices and
compares that to outcomes data from Florida ambulatory surgery
centers (ASC) for a one-year period. All 182 adverse incident reports
filed between April 2000 and April 2002 were reviewed. The reported
volume of office surgery procedures was obtained from the Florida
Board of Medicine and estimated for the study period. Ambulatory
surgery center injury and death statistics and procedure volumes were
obtained from the Florida Agency for Healthcare Administration and
the website http://www.floridahealthstat.com.
RESULTS: There were 13 surgically related deaths and approximately
141,404 procedures performed in offices between April 2000 and April
2002. There were 18 reported deaths and 2,316,249 procedures in
ambulatory surgery centers during 2000. Surgery related injury
occurred at a rate of 66 and 5.3 per 100,000 procedures in offices and
ambulatory surgery centers, respectively. The death rate was 9.2 and
0.78 deaths per 100,000 procedures performed in offices and
S-6 2003; 96; S-1–S-293
S-5
DOES CEREBRAL MONITORING IMPROVE RECOVERY the BIS and AEP groups (vs Control). However, the times to sitting up,
AFTER AMBULATORY ANESTHESIA? A COMPARISON OF the first time to take fluid, standing up, ambulating, “fitness” for
BIS AND AEP MONITORING DEVICES discharge, and actual discharge were significantly decreased in both the
AEP-titrated and BIS-titrated groups when compared to the Control
AUTHORS: J. Tang1, H. Ma1, P. F. White2, R. H. Wender1 group. There were no significant differences between the AEP and BIS
AFFILIATION: 1Department of Anesthesiology, Cedars-Sinai groups.
Medical Center, Los Angeles, CA, 2Department of Anesthesiology, UT CONCLUSIONS: Titration of desflurane using the AEP and BIS
Southwestern Medical Center at Dallas, Dallas, TX. monitors contributed to a faster emergence and earlier discharge home
following outpatient laparoscopic procedures. However, the AEP and
INTRODUCTION: The bispectral index (BIS) monitor has been BIS monitors were comparable in facilitating the recovery process.
reported to improve the titration of inhalational anesthetics during REFERENCES:
general anesthesia (1,2). The auditory evoked potential (AEP) has also 1. Anesthesiology 1997;87:842-8.
been shown to be a quantifiable measure of the sedative and hypnotic 2. Anesth Analg 2001;93:1165-9.
effects of anesthetic drugs. This study was designed to assess the
comparative effects of AEP and BIS monitoring on the utilization of Control BIS AEP
desflurane and the recovery profiles after ambulatory surgery. Age (yr) 45±8 40±7 39±14
METHODS: 30 consenting women undergoing outpatient laparoscopic
procedures were randomly assigned to one of three treatment groups. Weight (kg) 60±5 65±13 66±13
Anesthesia was induced with propofol, 2 mg/kg IV, and fentanyl, 1 µg/ Surgery time (min) 48±27 38±22 42±32
kg IV. Desflurane 2-4% in combination N2O 60% in oxygen was Eyes opening (min) 9±4 7±4 7±5
administered for maintenance of anesthesia. In the Control group, the
anesthesiologists were blinded to the AEP and BIS values, and Orientation (min) 10±5 7±4 7±5
desflurane was administered according to standard clinical practice. In Taking fluid (min) 167±48 100±57* 109±52*
the BIS group, desflurane was titrated to maintain a BIS value between Ambulation (min) 196±59 126±54* 120±56*
50-60. In the AEP group, desflurane was titrated to maintain an EEG-
derived index (AAI) between 15-25. The AAI and BIS values, as well Stay PACU time (min) 204±55 146±47* 149±44*
as the recovery times and side effects were recorded. Data were Actual discharge home (min) 216±58 144±43* 140±41*
analyzed using one-way ANOVA for continuous variables, paired t-test
for intragroup differences, and Chi-square test for categorical data. (*
p<0.05 vs Control).
RESULTS: During the maintenance period, the BIS and AAI values
were significantly lower in the Control group (mean BIS values of
42±12 and mean AAI values of 12±6) compared with the BIS-titrated
group (mean BIS of 60±15), and AEP-titrated group (mean AAI of
21±10), respectively. Even though they failed to achieve statistical
difference among the three groups, early recovery times to eyes
opening, extubation, and orientation were consistently shorter in both
S-6
BISPECTRAL INDEX MONITORING DURING SHORT REFERENCES:
SURGICAL PROCEDURES USING PROPOFOL ANESTHESIA 1.Br. J. Anaesth. 2001, 87 (3) : 505-7.
2.Anesthesiol. Clin. N. Amer. 2001, 19 (4) : 947-66.
AUTHORS: A. El-Hadidy 3.Anesthesiology 1997, 87 : 808-15.
AFFILIATION: Theodor Bilharz Research Institute, Cairo, Egypt.
INTRODUCTION: The present study aims to determine whether the
electroencephalogram derived bispectral index monitoring during short
term surgery using propofol infusion improves the accuracy of titration
of the drug, monitoring awareness and leads to rapid recovery.
METHODS: A total of 60 patients scheduled for minor surgery (<45
minutes long) were subdivided into 2 equal groups: Group (I) [standard
practice group], propofol adjustment was left to the discretion of the
investigator based on clinical signs. Propofol infusion was started at 140
g.kg-1.min-1 and modified to maintain hemodynamic stability and avoid
unwanted patient response. Group (II) [BIS group], propofol was
adjusted according to BIS monitoring to achieve a BIS score of 45-60.
RESULTS: A statistically significant decrease in propofol consumption
was found in the BIS group compared to the standard group. Also, a
significantly lower infusion rate and a lower total amount of propofol
were used. The heart rate and blood pressure did not significantly
change throughout the study. End points of recovery (eye opening,
response to simple commands) were reached at a faster level under BIS
monitoring.
DISCUSSION: The bispectral index (BIS) is a processed EEG
parameter incorporating coupling along with the frequency and
amplitude of EEG waveforms.[1] It has been proposed as a measure of
the pharmacodynamic anesthetic effect on the CNS. The level of 40-60
is the level of moderate hypnotic state or general anesthesia level with a
low probability of consciousness or awareness.[2] Patients under BIS
monitoring consume lower dosages of propofol, as measured by the
mean infusion rate at different times during surgery. This matches the
results of Gan et al.[3] However, special EEG electrodes are expensive
for such short anesthesia.
CONCLUSION: Routine BIS monitoring in standard anesthetic
practice can reduce propofol dosage and allow faster recovery with
potential economic benefits.
2003; 96; S-1–S-293 S-8
S-7
OROPHARYNGEAL WATER ACCUMULATION INCREASES amount of oropharyngeal suction per minute (group S 1, less than 0.2
SUSCEPTIBILITY TO CHOKING DURING DENTAL ml/min; group S 2, 0.2 - 0.7 ml/min; group S 3, more than 0.7 ml/min),
TREATMENT OF INTELLECTUAL DISABILITY UNDER and to the mean dose of propofol (group P 1, less than 5 mg/kg/hr; group
DEEP SEDATION P 2, 5 - 7 mg/kg/hr; group P 3, more than 7 mg/kg/hr).
RESULTS: The amount of total oropharyngeal suction, and that of
AUTHORS: A. Kohjitani1, T. Miyawaki1, M. Egusa2, H. Higuchi1, M. oropharyngeal suction per minute were significantly correlated with
Shimada1 intraoral use of water. The frequency of total choking episodes and that
AFFILIATION: 1Department of Dental Anesthesiology, Okayama of choking episode per minute were significantly correlated with the
University Graduate School of Medicine and Dentistry, Okayama, amount of oropharyngeal suction per minute. However, they did not
Japan, 2Department of Special Care Unit for Patients with Disability, correlate with the intraoral use of water and the mean dose of propofol.
Okayama University Hospital of Dentistry, Okayama, Japan. DISCUSSION: These findings suggest that 1) the higher the use of
water in the oral cavity, the higher the volume of water streaming down
INTRODUCTION: In the dental treatment of intellectual disability into pharyngeal space, even if we use intraoral vacuum during the
under deep sedation, we should often cease dental procedure due to dental procedures, 2) the higher the water accumulation in the
choking of patients, which is an airway protective reflex possibly oropharyngeal space, the higher the incidence of choking episodes.
induced by intraoral water use or by oral and/or pharyngeal secretion.
We investigated the relationship between frequency of choking
episodes and intraoral use of water, oropharyngeal water accumulation,
and mean dose of propofol, during dental treatment of intellectual
disability under deep sedation with midazolam and propofol, using a
continuous oropharyngeal suction catheter.
METHODS: Twenty-one (12 males and 9 females) intellectual
disability (mental retardation or autism) who scheduled for dental
treatment under deep sedation were studied. After induction of sedation
with midazolam (2 - 4 mg) and propofol (20 mg bolus and 4 - 9 mg/kg/
hr), we inserted a 14 Fr. suction catheter about 10 - 15 cm nasally, and it
was fixed at the nare where the pharyngeal suction could be done most
effectively. Airway maintenance was performed by chin-lift, nasal
airway insertion, or by both, to prevent subglottic airway obstruction.
The volume of suctional water from the pharynx was measured using a
graduated bottle situated in the suction circuit. As to counting
intraoperative choking, a series of choking episodes which induced by
an occasion was counted as 1 choking episode.
The patients were divided into 3 groups according to the intraoral water
use (group W1, treatments which scarcely require water; group W 2,
treatments which require moderate amount of water; group W 3,
treatments which require relatively large amount of water), to the
S-8
EFFECT OF LABETALOL ON SEIZURE ACTIVITY AFTER induced seizure activity.
ELECTROCONVULSIVE THERAPY REFERENCES
1. Weinger MB, Partridge BL, Hauger R et al: Prevention of the
AUTHORS: A. Recart1, S. Rawal1, P. White1, A. Macaluso1, L. cardiovascular and neuroendocrine response to electroconvulsive
Thornton2 therapy. Effectiveness of pretratment regimens on hemodynamics.
AFFILIATION: 1Department of Anesthesiology and Pain Anesth Analg 1991;73:556-62
Management, University of Texas Southwestern Medical Center, 2. Avramov MN, Stool LA, White PF et al: Effects of nicardipine and
Dallas, TX, 2Department of Psychiatry, University of Texas labetalol on the acute hemodynamic response to electroconvulsive
therapy. J Clin Anesth 1998;10:394-400
Southwestern Medical Center, Dallas, TX.
INTRODUCTION: Labetalol is commonly administered to patients * P < 0.05 vs control group
undergoing ECT to minimize the acute hemodynamic response Control Labetalol
following the electrical stimulus. However, the effect of labetalol on the Age (yr) 51±15 54±12
Weight (kg) 74±17 79±14
duration of the ECT-induced seizure activity remains controversial1,2. Motor seizure (sec) 42±14 40±13
Therefore, this randomized, double-blind, cross-over study was EEG seizure (sec) 58±22 57±22
designed to assess the hemodynamic effect of labetalol during ECT, as Baseline SBP 140±24 134±16
well as its effect on the duration of motor and EEG seizure activity. Pre ECT SBP 136±25 115±18*
METHODS: 25 consenting ASA I-III depressed patients undergoing Post ECT Peak SBP 173±32 155±21*
an acute series of ECT treatments under methohexital anesthesia were Max HR after ECT(bpm) 140±24 140±21
studied. After pre-treatment with glycopyrrolate 0.2 mg IV, patients Rescue labetalol doses(n) 1(0-4) 0 (0-1)*
were anesthetized with methohexital 0.75-1.25 mg/kg and remifentanil
0.75-1.25 g/kg. Following loss of consciousness, succinylcoline 1-1.25
mg/kg was administered. Approximately 1.5 min prior to administering
the electrical stimulus, either labetalol 10 mg or saline (2 ml) was
administered intravenously. The systolic (SBP) and diastolic blood
pressure (DBP) values, as well as heart rate (HR) values were recorded
at 1-2 min intervals. In addition, the duration of the motor and EEG
seizure activity was recorded. Rescue boluses of labetalol, 5 mg IV
were administered to treat persistently elevated SBP and DBP values
after ECT.
RESULTS: Pre-ECT treatment with labetalol 10 mg IV, reduced the
SBP immediate before and after the ECT stimulus. Labetalol had no
effect on the duration of either the motor or EEG seizure activity.
Finally, pretreatment with labetalol reduced the need for “rescue” doses
of labetalol after the ECT stimulus.
CONCLUSIONS: Labetalol, 10 mg IV, improved hemodynamic
stability during ECT without adversely affecting the duration of ECT-
S-10 2003; 96; S-1–S-293
S-9
THE EFFECT OF REMIFENTANIL ON SEIZURE DURATION opening, obeying commands, and the time to discharge did not differ
DURING ELECTROCONVULSIVE THERAPY (ECT) among the four study groups.
CONCLUSIONS: Remifentanil in doses ranging from 25 to 100 g IV,
AUTHORS: A. Recart1, S. Rawal1, P. F. White1, S. Byerly1, L. had no effect on the duration of ECT-induced seizure activity. In
Thornton2 addition, remifentanil did not prolong the recovery times or increased
AFFILIATION: 1Department of Anesthesiology and Pain side effects.
Management University of Texas Southwestern Medical Center, Dallas, REFERENCES:
TX, 2Department of Psychiatry University of Texas Southwestern 1.- Andersen, FA Arsland D, Holst-Larsen HEffects of combined
Medical, Dallas, TX. methohexitone-remifentanil anesthesia in electroconvulsive therapy.
Acta anesthesiol Scand 2001;45 830-33
INTRODUCTION: Remifentanil (Ultiva®) is a short-acting opioid
which is used for induction and maintenance of general anesthesia. Remifentanil dose (mcg) 0 25 50 100
Administration of remifentanil in combination with methohexital has Depression Score (n) 15±9 13±7 15±8 12±8
been reported to be associated with increased seizure duration in Motor Seizure (min) 43±10 45±15 39±19 39±20
patients undergoing ECT1. This prospective, randomized, double-blind,
placebo-controlled crossover study was designed to compare different EEG Seizure (min) 56±16 60±22 57±12 58±34
bolus dosages of remifentanil on the duration of ECT-induced motor Eye opening (min) 7±4 6±3 7±2 9±3
and EEG seizure activity. Obeys commands (min) 11±6 8±3 9±3 12±14
METHODS: 10 consenting patients with major depressive disorders
receiving maintenance ECT participated in this study. A total of 40 ECT Discharge time (min) 25±4 22±3 24±6 26±3
treatments were evaluated. All patients were premedicated with
glycopyrrolate, 0.2 mg IV, and hypnosis was induced with a standarized
IV bolus of methohexital 1 mg/kg and muscle paralysis was achieved
with succinylcholine, 1.2 mg/kg IV. All patients received one of three
different doses of remifentanil 25, 50 and 100 g or saline in a random
sequence immediately after methohexital for four consecutive ECT
treatments. A fixed "supra" threshold electrical stimuli was
administered to elicit a seizure, and the times from the stimulus to the
cessation of the motor and EEG seizure activity were noted. Standarized
psychomotor recovery times were also assessed at specific intervals,
statistical analysis consisted on ANOVA with p-values <0.05
considered statistical significance.
RESULTS: Three males and seven females with a mean (± SD) age of
54 ± 16 yr, and weight of 75 ± 18 kg participated in the study. All
patients had similar baseline Hamilton depression scores. The duration
of motor and EEG seizure activity were not significantly different
among the four treatment groups. Furthermore,recovery times to eye
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THE EFFICACY OF REMIFENTANIL IN AMBULATORY 4.2 min, p = 0.04. The patients‘ self scoring of pain showed significant
PATIENTS differences in both PACU‘s, with remifentanil patients experiencing
less pain in both units: p = 0.005 and p = 0.033 respectively.
AUTHORS: M. Rafizadeh, A. Lele, R. Dorian DISCUSSION: Remifentanil shortens recovery time spent in the
AFFILIATION: Saint Barnabas Medical Center, Livingston, NJ. PACU and enables patients to experience less pain. Patients‘ recovery
from pain is quicker, leading to a shorter stay in the PACU. This, in
INTRODUCTION: Remifentanil‘s short duration of action is due to turn, may reduce patient costs in the PACU.
its rapid hydrolysis by nonspecific esterases. Patients receiving
remifentanil demonstrate rapid recovery. This feature of the drug makes
it ideal in patients undergoing procedures that are relatively short in
duration.
METHODS: This retrospective study investigates the use of
remifentanil in female patients coming for ambulatory gynecological
procedures at the Women‘s Center of this institution. The medical
records of 189 patients for a 4 month period were analyzed and were
divided into two groups: one group was administered remifentanil; the
second group was administered sevoflurane. Patients in both groups
received N2O with O2 and propofol as an induction agent. A bis monitor
was used with all patients. Propofol was administered incrementally to
maintain the bis at values between 40–60.
RESULTS: Remifentanil was administered to 116 patients: median age
= 34 years, range 19 to 74 years. Seventy-three patients were
administered sevoflurane: median age 34 years, range 18 to 59 years.
Anesthesia times (means + SEM) for the two groups were similar:
remifentanil 30.7 + 2.8 min and the control 28.5 + 1.0 min, p = 0.54.
There was no significant difference in the incidence of nausea and
vomiting between the remifentanil patients (5 patients, 4.3%) and in the
sevoflurane patients (6 patients, 8.2%). The time (means + SEM) spent
in PACU by the two groups was significantly different: remifentanil
40.4 + 1.4 min and sevoflurane 49.8 + 2.6 min, p = 0.002. The last
Aldrete scoring taken to determine patients going to the step down
PACU was significantly different: remifentanil 9.0 + 0.1 and
sevoflurane 8.1 + 0.2, p = 0.001. The time spent in the step down PACU
was not significantly different, but the remifentanil group‘s time was
shorter: remifentanil 62.8 +2.0 min, sevoflurane 66.7 + 3.5 min, p =
0.33. The total time spent in both PACU‘s by the groups was
significantly different: remifentanil 99.7 + 2.9 min, sevoflurane 110.3 +
2003; 96; S-1–S-293 S-12
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PATIENT-CONTROLLED SEDATION AND ANALGESIA recorded. Data was analyzed by T-test for independent samples and
WITH REMIFENTANIL-PROPOFOL FOR SHOCK WAVE ANOVA for repeated measures. P<0.05 was considered significant.
LITHOTRIPSY; HAVE WE REACHED OUR ULTIMATE RESULTS: Patient characteristics, duration of the procedure, stone
GOAL IN PATIENT COMFORT AND SAFETY? localization were similar between the two groups. There was no
difference between the groups in terms of mean blood pressure and
AUTHORS: A. A. Yilmaz, S. Karabayirli, T. Korkmaz, Y. Ates, F. heart rate values. SpO2 decreased significantly(<90%) at 10 min in
Tuzuner group I (p<0.05).Sedation scores were higher in group I at 5, 10, 15 and
AFFILIATION: Ankara University Medical Faculty, Ankara, Turkey. 20 min compared to group II (p<0.05). Mean dose of propofol and
remifentanil administered in group I was higher than the dose requested
INTRODUCTION: Patient-controlled sedation and analgesia (PCSA) and delivered by PCSA pump in group II (p<0.01).Recovery time was
is a novel field of use for monitored anesthesia care (1, 2). Combination longer in group I (p<0.05). Mean pain score regarding the procedure
of propofol- remifentanil has been used for PCSA without a lockout was <4 in both groups (10 pt scale). Patients in both groups were
interval in a recent study in patients undergoing extracorporeal shock equally satisfied with the analgesic and sedative technique used.
wave lithotripsy (SWL)(1). Although promising in terms of patient DISCUSSION: In this study the PCSA protocol with propofol-
comfort the high incidence of adverse effects have indicated a PCSA remifentanil seems to provide adequate sedation and analgesia without
protocol incorporating a proper lockout interval should be investigated. significant side effects and with decreased drug consumption. Safer and
In this study a low-dose continuous infusion of propofol-remifentanil effective protocols for PCSA may encourage its more extensive usage.
combination was compared with a PCSA protocol including a REFERENCES:
presumably appropriate lockout interval. 1) Anesth Analg 2001;93:1227-32. 2) Gastrointest Endosc 2001;54:1-7.
METHODS: After IRB approval and patient consent was obtained;
fifty ASA I-III adult patients undergoing SWL procedure were
randomly allocated to two groups by sealed envelope technique.
Patients with allergies to the study drugs, at risk for pulmonary
aspiration, who could not understand the concept of PCSA before
randomization were not included. Group I(n=25) solution containing
remifentanil 2g/mL and propofol 1mg/mL was infused continuously at
3 mL/min following a loading dose of 10mL. Group II(n=25) PCSA
solution containing remifentanil 4g/mL and propofol 2mg/mL was
delivered using Abbott Pain Management Provider 13960-36 patient
controlled analgesia pump (Abbott Laboratories, Chicago,IL) with a
setting of 10mL loading dose, 5 minutes lockout interval and a bolus
dose of 5mL on demand. Rescue medication in group I was 5mL of the
study solution delivered by the one of the attending authors. Follow up
parameters during SWL were; heart rate, noninvasive blood pressure,
peripheral oxygen saturation (SpO2), respiratory rate, sedation score
and faces scale score. After the procedure; recovery time, patient’s
recall of procedure, pain score(VAS), satisfaction and drug usage were
S-12
A NOVEL MIXTURE OF PROPOFOL, ALFENTANIL AND baseline. After sedation and block, SBP decreased 6% from baseline
LIDOCAINE FOR OPHTHALMIC SURGERY UNDER MAC (P<0.005). Although 50% patients had recall, it was considered non
stressful. Of the 39 patients undergoing < 30 minute procedures, only 7
AUTHORS: Z. Fang, M. A. Keyes, F. Sabzevar (18%) required midazolam for anxiolysis during the procedure.
AFFILIATION: David Geffen School of Medicine at UCLA, Los Patients‘ and surgeons‘ satisfaction scores were 9.77 +0.58 and
Angeles, CA. 9.60+0.78, respectively.
INTRODUCTION: The combination of propofol, alfentanil and Apnea
Non
lidocaine is effective in providing sedation and analgesia for ophthalmic Had sec/ No ebm RD- need SBP SBP
# pt N/V stressful
surgery with regional block under MAC. With IRB approval, we ss/drr Hm/ebm/cop Only FC airway (pre –bl) (post – bl)
recall
retrospectively analyzed 89 charts of patients sedated with this support
technique. 71 69 11 24 2 45
METHODS: 6 ml of propofol (10mg/ml), 2 ml of alfentanil (500g/ml) 89 13.7+22.97 -7.9+21.99 0
(80%) (78%) (12%) (27%) (2%) (50%)
and 2 ml of 2% lidocaine (A6-2-2 mixture) were freshly mixed in a 10 P<0.0001 P<0.005
ml syringe. The bolus dose was determined based on the patients‘ age: 5 Sec =spontaneous eye closure; ss =sluggish speech; cop =complaint of pain; hm =head
g/kg of alfentanil (and 0.3 mg/kg of propofol) for patients > 75 years; movement; ebm =eyebrow movement; RD-FC =respiratory depression but able to follow
the dose increased 1 g/kg per 10-year decrease in age, up to 9 g/kg of command; SBP(pre-bl) =difference of systolic blood pressure between that prior to sedation and
alfentanil ( 0.54mg/kg of propofol) for patients < 45years. The bolus pre-op baseline; SBP (post-bl)=Difference of SBP between that after sedation and pre-op
baseline; N/V =nausea and vomiting.
was delivered by infusion pump and followed by a continuous infusion
of the mixture with 0.75 g/kg/min alfentanil (and 45 mcg/kg/min of CONCLUSIONS: With low incidence of need for airway support, no
propofol) until block completion. Block was performed at 1 minute pain during the infusion and no N/V, the novel mixture of propofol,
after bolus finished. oxygen was provided by nasal cannula and blow alfentanil, and lidocaine (A6-2-2 mixture) technique provided adquate
by. BP, SaO2, ECG, capnography, clinical signs of sedation (spontaneous analgesia and sedation in a predictable time manner (3-4 minutes) and
eye closure, sluggish speech, and decrease of respiratory rate), hemodynamic stability for ophthalmic surgery under regional block.
responses to block (head movement, eyebrow movement, complaints of The sedation and comfort provided by the mixture typically lasts for
pain), need for airway support, N&V, pain due to propofol infusion and approximately 30 minutes making the technique suitable for a variety of
recall were recorded. Patient and surgeon satisfaction was scored (1-10; short procedures with blocks under MAC.
10 for complete satisfy) by standardized questioning. Chi-square test
and T-test were used for statistical analysis. P< 0.05 was significant.
RESULTS: The average time for bolus was 0.29 + 0.04 second per g
alfentanil. 78% achieved analgesia and sedation without any adverse
response to block. 12% achieved good analgesia and sedation with only
eyebrow movement upon needle insertion. 27% had respiratory
depression but were able to follow commands and maintained adequate
ventilation. 2% had brief apnea alleviated by chin lift or jaw thrust.
None had pain due to mixture infusion or N&V. Prior to sedation,
average SBP was significantly increased (P<0.0001) compared to
2003; 96; S-1–S-293
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DEXMEDETOMIDINE SEDATION DURING REGIONAL midazolam (both DMED and propofol 0.04mg/kg) and fentanyl
ANESTHESIA: A PILOT STUDY (DMED 2.6 mg/kg; propofol 3.6 mg/kg) supplemented as "rescue’
medication was also not significantly different between the groups.
AUTHORS: L. L. Stice-Beredino, T. Fahey, III, P. Dhar DISCUSSION: DMED is as effective as propofol in maintaining a
AFFILIATION: New York-Presbyterian Hospital, New York, NY. stable level of sedation. However, sedation with DMED requires fewer
dosage adjustments, and since DMED is more potent than propofol, it
INTRODUCTION: In this pilot study, dexmedetomidine (DMED) was requires significantly less volume to maintain a constant level of
compared to propofol for its ability to maintain a calm and cooperative sedation. The cost between the two drugs when used for sedation is
patient during neck surgery under regional anesthesia. comparable. Propofol requires more careful titration during deep
METHODS: After IRB approval and informed consent, twelve patients sedation to avoid respiratory depression and the requirement for airway
presenting for partial/total thyroidectomy or parathyroidectomy, were support, making it more labor intensive to use. DMED maintains deep
randomly assigned to the DMED (n=6) or propofol (n= 6) group. There levels of sedation without respiratory depression or any need for airway
were no significant differences in the average age (52.2 yrs) or weight support.
(66.6 kg) between the patients in each group. Thyroidectomy patients REFERENCES:
received bilateral superficial cervical plexus block placed by the 1. Controlled sedation with alphaloxone-alphadolone. Brit Med J. 1974,
anesthesiologist. Parathyroidectomy patients received local anesthesia 2:656-659.
administered by the surgeon. DMED infusion was started with a 1 g/kg
bolus over 10 minutes and titrated from 0.2-0.7 g/kg/hr. Propofol
infusion was started at 25 g/kg/min and titrated up to 100 g/kg/min.
Heart rate, blood pressure, end-tidal carbon dioxide (PetCO2),
respiratory rate, oxygen saturation (SpO2), and Ramsay sedation scores
were recorded throughout surgery by the anesthesiologist. If the patient
had not reached a Ramsey sedation score of 4 despite a maximal
infusion rate, midazolam and fentanyl were administered. A scale of 1-
10 (1 = agitated, frequent movement; 10 = calm, cooperative) was used
by the surgeon (blinded to the agent used) to evaluate the quality of
sedation of each drug.
RESULTS: Significantly less DMED (39.3ml vs. 80.7 ml propofol, p =
0.02) and fewer adjustments in infusion rate (2 vs. 5, p = 0.001) were
required to maintain the Ramsay score 4. The cost between the volumes
infused was similar (DMED $30; propofol $29.86, US). No DMED
patient required airway support, while two propofol patients did.
Surgeons’ satisfaction with DMED was greater than with propofol (7.5
vs. 5.7). There were no significant differences between groups with
regard to SpO2 (99.1% vs. 98.7%), PetCO2 (35.2 mmHg vs. 39.6
mmHg), respiratory rate (14.9 bpm vs. 14.0 bpm), or the percentage of
time the Ramsay score was 4 (44.4% vs. 53.5%). The amount of
Vascular – Basic Science
Cardiothoracic and
Cardiothoracic and Vascular –
Basic Science
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ANESTHETIC PRECONDITIONING: EFFECTS ON LATENCY DISCUSSION: In this model of global ischemia, when ischemia
TO ISCHEMIC INJURY IN ISOLATED HEARTS duration is short (20 min) or long (45 min), APC failed to protect
against decreases in contractile function or against increases in O2•-
AUTHORS: L. G. Kevin, P. Katz, M. L. Riess, E. Novalija, D. F. formation and infarction, thus a window-period exists wherein APC is
Stowe effective. This suggests that although APC increases latency to
AFFILIATION: Medical College of Wisconsin, Milwaukee, WI. ischemic injury, clinical application of APC may be limited to those
patients who experience ischemia of relatively brief duration. APC-
INTRODUCTION: Anaesthetic preconditioning (APC) is the induced protection against vascular endothelial dysfunction is not
phenomenon whereby brief exposure to a volatile anesthetic leads to a limited by prolonged ischemia in this range however. This may reflect
state of resistance to the effects of ischemia and reperfusion. APC has the lower metabolic rate of vascular endothelium compared to
been shown to be protective with regard to several variables including myocytes, leading to increased resistance to ischemia, or alternatively it
left ventricular pressure (LVP), coronary flow (CF), free radical release may reflect protective effects of endothelial nitric oxide.
at reperfusion, and infarct size. To our knowledge all previous
investigations have used ischemic time as the independent variable and % Improvement in LVP and CF (APC vs CON) (*P < 0.05)
have quantified changes in dependent functional and structural Duration of Ischemia Developed LVP Coronary Flow
variables. A more meaningful measure of the efficacy and potential 20 min 8% 2%
clinical utility of APC may be the incremental time during ischemia that 25 min 24%* 32%*
APC affords before irreversible ischemic damage occurs. The purpose 30 min 37%* 34%*
of his study was to define the critical limits of efficacy of APC by 35 min 28%* 28%*
varying the ischemic time. 40 min 14% 33%*
METHODS: Isolated guinea pig hearts were perfused in crystalloid 45 min 3% 27%*
buffer at 55 mmHG; developed LVP, coronary flow (CF), superoxide
(O2•-) formation and infarct size were measured. Hearts underwent
preconditioning (two pulses of sevoflurane 0.6 mm for 5 min) (APC), or
no treatment (CON) prior to global ischemia and 120 min reperfusion.
For both APC and CON hearts ischemia durations were 20, 25, 30, 35,
40 and 45 min (n=6/ischemia duration/treatment).
RESULTS: At 120 min reperfusion after ischemia, developed (systolic
– diastolic) LVP was increased and O2•- formation and infarct size were
decreased in APC compared to CON for ischemia durations 25 min-40
min; a bell-shaped distribution for APC-induced protection was
apparent (Table). There were no differences in these variables when
ischemia was 20 min or 45 min. CF and vasodilator response to
bradykinin were similar between APC and CON when ischemia was 20
min, but were increased in the APC group for other ischemia durations.
APC-induced preservation of CF and responsiveness to bradykinin
were consistent for ischemia durations greater than 20 min (Table).
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DELAYED ANESTHETIC PRECONDITIONING OF THE is equal to the immediate effect when the time between VA pretreatment
ENDOTHELIUM AGAINST CYTOKINE-INDUCEDCELL and cytokine exposure is extended to 24-48 hrs in HMECs.
DEATH CONCLUSION: Isoflurane pretreatment has immediate and delayed
protective effects against cytokine-induced injury. While other studies
AUTHORS: M. M. de Klaver, M. Buckingham, G. F. Rich only investigated delayed preconditioning after 12 or 24 hours,2-5 our
AFFILIATION: University of Virginia Health System, results suggest that anesthetic preconditioning may be time-dependent.
Charlottesville, VA. Protection is abolished after 4 hrs delay but regained after 16 hrs, and
the delayed effects after 24 or 48 hrs are equal to the immediate effects.
INTRODUCTION: We recently showed that volatile anesthetic This study suggests that delayed anesthetic preconditioning has the
pretreatment has immediate protective effects against cytokine-induced potential to protect the endothelium from inflammation.
cell death in endothelial and vascular smooth muscle cells. 1 A number REFERENCES:
of studies have described a second window for ischemic 1. de Klaver MJM et al: Anesthesiology; 2002; 97:24-32
preconditioning (IPC), in which the myocardium is protected against an 2. Bernardo NL et al: Am J Physiol 1999; 276: H1323-30.
ischemia-reperfusion insult, 12-24 hrs after the IPC stimulus. 2-4 3. Baxter GF et al: Cardiol 2001; 96: 329-44.
Likewise, Isoflurane (1 %) induces delayed (24 hrs) cardioprotective 4. Carrol R et al: Basic Res Cardiol 2000; 95: 243-9.
effects in rabbit hearts. 5 The objective of the present study was to 5. Tonkovic-Capin M et al: Am J Physiol 2002; 283: H61-68
investigate whether isoflurane also triggers delayed protection in
endothelial cells from cytokines-induced cell death. We preformed a
time course to compare the immediate protection with the delayed
effects of isoflurane pretreatment.
METHODS: In our cellular model of inflammation human
microvascular endothelial cells (HMECs), were exposed to cytokines
(0.1 ng/ml TNF, 5.0 ng/ml IFN and 5.0 ng/ml IL1, dissolved in
medium) for 72 hours, after pretreatment with isoflurane for 30 minutes
in an airtight chamber by ventilating the chamber with 100% oxygen
and 1.5% isoflurane. The exposure to cytokines was initiated directly
after isoflurane pretreatment or with a period of delay, (1, 4, 12, 16, 20,
24 and 48 hrs). After cytokine exposure, the total number of cells and
were counted and the surviving cells were identified using trypan blue
exclusion.
RESULTS: Isoflurane pretreatment had immediate and delayed
protective effects against cytokine-induced cell injury and death
(figure). While the immediate effect of isoflurane pretreatment is lost if
the time between isoflurane pretreatment and cytokine exposure is
extended beyond 4 hrs, the protective effect is restored when the
interval between isoflurane pretreatment and cytokine exposure is
extended to 16 hrs or longer. Importantly, the delayed protective effect
2003; 96; S-1–S-293 S-17
S-16
ANESTHETIC PRECONDITIONING TRIGGERED BY ROS DISCUSSION: APC-induced protection is due, at least in part, to ROS
IMPROVES MITOCHONDRIAL ATP SYNTHESIS AND formation triggered by sevoflurane. Moreover, mitochondrial oxidative
DECREASES ROS FORMATION AFTER ISCHEMIA IN phosphorylation is better preserved as shown by a higher rate of ATP
GUINEA PIG HEARTS synthesis after APC. This may be due to less damage to the electron
transport chain as shown by reduced ROS formation during ischemia
AUTHORS: E. Novalija, L. G. Kevin, J. S. Heisner, M. M. Henry, J. T. and initial RP.
Eells, D. F. Stowe REFERENCES:
AFFILIATION: Medical College of Wisconsin, Milwaukee, WI. 1) American Journal of Physiology Heart Circulatory Physiology 283:
H44-H52, 2002.
INTRODUCTION: The anesthetic sevoflurane, if given transiently
before ischemia (anesthetic preconditioning, APC), reduces infarct size
and reactive oxygen species (ROS) formation on reperfusion (RP).1
ROS scavenging during anesthetic exposure blocks protection and
restores formation of ROS on RP.1 In this study we tested if APC
mediates protection in intact hearts and isolated mitochondria by
preserving mitochondrial bioenergetics as shown by improved ATP
synthesis and reduced ROS formation on reperfusion.
METHODS: Guinea pig hearts were isolated and perfused with
crystalloid buffer at 55 mmHg and developed LVP was measured. 28
hearts were subject to 30 min global ischemia and infarct size was
measured at 120 min RP. Groups were: untreated (ISC), sevoflurane
(APC, 2.7 vol%), a ROS scavenger MnTBAP (TBAP, 40 M) and
sevoflurane with the ROS scavenger (APC+TBAP). TBAP was infused
5 min before, during and 5 min after APC. All drugs were washed out
15 min before ischemia. An additional 20 hearts, subject to the same
protocol, were removed at 1 min RP to measure ATP synthesis
(luciferase luminometry) and ROS formation (DCHF fluorescence) in
mitochondria isolated by differential centrifugation. A CON group was
not subject to ischemia and RP. Data are means ±SEM (p< 0.05; * vs.
ISC).
RESULTS: At 120 min RP, LVP (mmHg) was improved and infarct
size (% heart weight) was reduced after APC (55±2*, 22±2*%) vs. ISC
(22±2, 53±3%), TBAP (25±3, 57±2%), APC+TBAP (23±3, 56±4%).
Mitochondrial ROS formation (units, 120 min incubation) and ATP
synthesis rate (100% CON), respectively, were CON (405±22*, 100*%)
vs. APC (387±59*, 92±2.6*%), ISC (601±92, 29±2.5%), TBAP
(582±50, 28±2.0%), and APC+TBAP (591±52, 29±2.9%).
S-17
IMPACT OF ISOFLURANE DURING SIMULATED depressed in both groups throughout reperfusion. Fura-2 ratio climbed
MYOCARDIAL ISCHEMIA/REPERFUSION ON in both groups over time. This increase was significantly more
INTRACELLULAR CALCIUM, ARRHYTHMIA AND prominent in isoflurane treated cardiomyocytes where intracellular
CONTRACTILITY calcium more than tripled until the end of reperfusion (p < 0.05). In the
control group the rise of calcium was not as steep. Calcium levels even
AUTHORS: M. Dworschak1, D. Breukelmann2, J. D. Hannon2 dropped during early reperfusion but were overall about 50 % higher
AFFILIATION: 1Anesthesia Research, Mayo Clinic, Rochester, MN, than baseline after reperfusion. Significantly more isoflurane treated
2
Anesthesia Research, Mayo Clinic, Rochester, MN. cells became arrhythmic during ischemia and remained arrhythmic
during reperfusion. Contractility declined in the course of ischemia
BACKGROUND: Administration of isoflurane is common before and independently of treatment. However, the recovery and the overshoot
during myocardial revascularisation. Isoflurane, however, interferes that control cells exhibited during early reperfusion was absent in
with the calcium handling capacity of cells, can inhibit the respiratory isoflurane treated cardiomyocytes.
chain and produce oxygen radicals. We therefore investigated how CONCLUSION: Isoflurane given during simulated ischemia and
isoflurane alters intracellular calcium and pH, and interferes with reperfusion leads to a marked rise of intracellular calcium as compared
cellular contractility and stability of membrane potential when applied to control cells that is independent of pH changes. Additionally,
along with simulated ischemia and reperfusion. isoflurane treated cells also exhibited a higher incidence of arrhythmic
METHODS: After institutional approval rats were anesthetized and events and a depressed contractility that did not reach baseline values
their hearts rapidly excised. Single cardiomyocytes were obtained after throughout reperfusion. These potentially harmful effects may be
enzymatic digestion. After staining with the ratiometric calcium related to diminished calcium efflux and excessive oxygen radical
fluorescent dye Fura-2 and the pH sensitive dye BCECF they were generation.
transferred into a flow-through chamber on the platform of an inverted
microscope. Ischemia was simulated for 30 minutes by superfusing the
cells with an acidic (pH: 6.3) substrate free modified Tyrode's solution
containing 10 mM deoxy-glucose to inhibit glycolysis. It was
vigorously bubbled with N2, which was also introduced underneath the
hood that covered the superfusion chamber to prevent equilibration of
pO2. These measures reduced pO2 to below 15 mmHg. Isoflurane
treated cells (n = 30) were also exposed to 1MAC of isoflurane during
ischemia (30 min) until the end of reperfusion (50 min) while control
cells (n = 40) were exposed to air only. Fluorescence data were
determined in five minute intervals as well as the occurrence of
arrhythmic events and semiquantitative contractility. The cells were
continuously stimulated at a frequency of 0.25 Hz. Multivariate tests
with Bonferroni correction were employed for statistical analysis.
RESULTS: Intracellular calcium concentration is given as Fura-2 ratio.
Ischemia caused a drop of pH from 7.3 to 6.4 in both groups without
any difference between groups. After a brief recovery it remained
S-19 2003; 96; S-1–S-293
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HYPOTHERMIA INCREASES MITOCHONDRIAL CA2+ BUT size was 56±2 vs 19±2* %, respectively.
ATTENUATES MITOCHONDRIAL CA2+ OVERLOAD DURING CONCLUSION: m[Ca2+] controls activation of Ca2+ sensitive
MYOCARDIAL ISCHEMIA AND REPERFUSION IN GUINEA dehydrogenases and oxidative phosphorylation in the mitochondria. A
PIG INTACT HEARTS mild increase in m[Ca2+] accelerates ATP synthesis during increased
energy demand whereas excessive m[Ca2+] overload has been causally
AUTHORS: M. L. Riess1, L. G. Kevin1, A. K. Camara1, S. S. Rhodes2, implicated in IR injury and cell death. We show that hypothermia
D. F. Stowe1 attenuates myocardial m[Ca2+] overload during IR, as evidenced by on-
AFFILIATION: 1Medical College of Wisconsin, Milwaukee, WI, line fluorescence measurements in intact hearts. Mitochondrial
2
Marquette University, Milwaukee, WI. protection helps to explain preservation of cardiac function and tissue
viability after hypothermic IR.
INTRODUCTION: Cardiac ischemia/reperfusion (IR) injury is
associated with mitochondrial (m)[Ca2+] overload. Hypothermia
protects against IR injury. We hypothesized that hypothermia attenuates
m[Ca2+] overload during IR.
METHODS: Langendorff-prepared guinea pig hearts (n = 12) were
loaded with the Ca2+-specific fluorescent probe indo 1. After MnCl2
perfusion to quench cytosolic Ca2+ fluorescence, mitochondrial Ca2+
fluorescence was excited at 350 nm and emissions were measured at
390 and 460 nm via a bifurcated fiberoptic cable placed against the left
ventricular wall. To account for changes of the dissociation constant for
indo 1 (Kd) with cooling and rewarming, the Kd was temperature-
corrected at each individual time point. Left ventricular pressure (LVP)
was measured isovolumetrically with a pressure transducer and a saline-
filled latex balloon. After stabilization, hearts were either kept at 37ºC
or cooled to 17ºC for 20 min before 30 min of global ischemia, followed
by 120 min reperfusion at 37ºC. Infarct size was determined using TTC
staining and cumulative planimetry. All values are mean±SEM.
Statistics: Student’s t-test (*P<0.05).
RESULTS: Baseline m[Ca2+] was not different between groups and
averaged 154±4 nM. Ischemia at 37ºC resulted in a continuous increase
in m[Ca2+] which peaked at 54±24* nM. Cooling to 17ºC significantly
increased m[Ca2+] to 210±8* nM before ischemia which did not further
increase m[Ca2+]. On reperfusion m[Ca2+] fluorescence returned to pre-
ischemic values faster in hypothermic than in normothermic hearts. At
120 min reperfusion, developed LVP (% of pre-ischemia) was 49±2 %
for normothermic hearts, but 98±3* % for hypothermic hearts; infarct
S-19
REDUCED LEUKOCYTE RECRUITMENT IN MICE compared to wt (32±2 vs. 49±2 % infarct/AAR, u-PAR-/- vs. wt, n=9/7,
DEFICIENT FOR THE UROKINASE RECEPTOR (U-PAR) IS p<0.0001). To test to what extent reperfusion injury depended on u-
ASSOCIATED WITH SMALLER INFARCTS AND IMPROVED PAR, we examined u-PAR- or wt-PMN homing to ischemic wt-
REGIONAL FUNCTION AFTER TRANSIENT MYOCARDIAL myocardium (64±16 u-PAR-PMN vs. 228±115 wt-PMN, n=3). Only a
ISCHEMIA trend for a reduction of PMN-homing was observed when wt-PMN
were injected in u-PAR-/--mice (150±53 wt-PMN, n=3, ANOVA:
AUTHORS: J. Mersmann1, J. Larmann1, M. Lox1, S. Brodner1, H. p<0.05). 7 days after MI/R CD45-positive leukocytes are more
Van Aken1, M. Dewerchin2, P. Carmeliet2, G. Theilmeier1 abundant in wt-infarcts, whereas no leukocytes are detected in u-PAR-/--
AFFILIATION: 1Klinik und Poliklinik für Anästhesiologie und infarcts. 4 days post MI/R wt-wall-thickening fraction had significantly
operative Intensivmedizin, Münster, Germany, 2CMVB_CTG, Leuven, decreased by 26±7% (n=5, p<0.01) while regional function of u-PAR-/--
Belgium. mice remained largely unchanged (-5±5%, n=4).
DISCUSSION: u-PAR deficiency significantly reduces infarct size
INTRODUCTION: Myocardial ischemia and reperfusion (MI/R) after transient myocardial ischemia by ameliorating reperfusion injury.
poses a vital threat to over 5 million patients undergoing anesthesia This effect is associated with reduced leukocyte recruitment to post-
each year. As leukocyte extravasation is a key event in MI its ischemic tissue. Reduction of post-ischemic inflammation improves
modulation may be a valid therapeutic strategy. Leukocyte adhesion to myocardial wound healing and thus mitigates the functional
endothelial cells is regulated by integrins. The urokinase receptor (u- consequences of myocardial ischemia. We therefore predict u-PAR to
PAR) has been recognized to be critically involved in the regulation of - be an attractive target for modulation of reperfusion injury.
integrin activity(1). We therefore examined its role in MI/R using u- REFERENCES:
PAR deficient (u-PAR-/-) or wild type mice (wt). 1.Wei, et al., Science 273, 1551-5 (1996)
METHODS: 12-week-old gender-matched mice were barbiturate-
anesthetized and ventilated with isoflurane in O2. To induce MI/R the
left anterior descending coronary artery (LAD) was ligated for 30
minutes. Reperfusion lasted 3 or 24 hours. Mice were saline-perfused
and LV, area at risk (AAR) and infarct were planimetrically delineated
using TTC/coomassie blue. Bone marrow-derived polymorphnuclear
leukocytes (PMN) were fluophor-labeled and injected upon reperfusion.
PMN were counted on 100m sections by epifluorescence microscopy.
To detect inflammatory cells in the infarcted tissue sections of paraffin-
embedded hearts were stained iummunohistochemically with
monoclonal antibodies against CD45. Using 2D-guided M-mode
echocardiography we examined regional ventricular function before
and after myocardial ischemia using the wall thickening-fraction.
RESULTS: After 3h of reperfusion, u-PAR-/--infarcts were smaller than
wt-infarcts (24±9 vs. 35±2.5 % infarct/AAR, u-PAR-/- vs. wt, n=7/5,
p<0.05). Within 24h infarcts enlarged significantly less in u-PAR-/-
2003; 96; S-1–S-293 S-21
S-20
FENTANYL PROTECTS STUNNED MYOCARDIUM IN DOGS differences in coronary blood flow or coronary vascular resistance
among groups.
AUTHORS: T. Hara, M. Oshibuchi, O. Yoshitomi, S. Cho, S. CONCLUSIONS: Preischemic administration of fentanyl markedly
Tomiyasu, K. Sumikawa improves myocardial contractile dysfunction dose-dependently after
AFFILIATION: Nagasaki University School of Medicine, Nagasaki, ischemia/reperfusion in dogs. Fentanyl protects myocardium against the
Japan. ischemia/reperfusion injury in vivo.
Although the activation of opioid receptors might be a mechanism in
myocardial protection against the ischemia/reperfusion injury,
cardioprotective effects of fentanyl are still controversial. In the
Langendorff rat heart, fentanyl had no effects in recovery of
contractility on stunned myocardium. Although fentanyl significantly
improved contractility on stunned myocardium in the halothane
anesthetized open chest dogs, volatile anesthetics has cardioprotective
effects in stunned myocardium. We investigated the cardioprotective
effects of fentanyl with no volatile anesthetics on stunned myocardium
in dogs.
METHODS: After the approval of Animal Care Committee, 15 dogs
were anesthetized with alpha-chloralose and acutely instrumented for
measurements of systemic and coronary hemodynamics. The dogs were
allocated to one of 3 groups (n=5 for each group) to receive each
regimen; low-dose fentanyl (0.01 mg/kg + 0.01 mg/kg/h), high-dose
fentanyl (0.1 mg/kg + 0.1 mg/kg/h) or drug vehicle (control). Stunned
myocardium was produced by 15-min occlusion of left anterior
descending coronary artery (LAD) and 90-min reperfusion in all dogs.
Fentanyl was administered starting 15 min before LAD occlusion until
the onset of the ischemia. Measurements were made before and during
LAD occlusion and after LAD reperfusion. Statistical analysis was
made by ANOVA followed by Scheffe’s test. P < 0.05 was considered
significant.
RESULTS: There were no significant differences in demographic data
among groups. In the control group, %SS 90 min after reperfusion was
31.5 ± 5.1 % of baseline value. In the group of low-dose fentanyl, %SS
showed no significant change compared to the control group. In the
group of high-dose fentanyl, %SS showed improved recovery
compared to the control group and the value 90 min after reperfusion
was 69.3 ± 6.2 % of baseline value. There were no significant
S-21
THE EFFECT OF BUPIVACAINE ON MYOCARDIAL TISSUE and the rate of decrease was four times faster in sham compared to
HYPOXIA AND ACIDOSIS DURING VENTRICULAR bupivacaine treated dogs.
FIBRILLATION DISCUSSION: These results show that in sham treated dogs,
myocardial tissue oxygen and pH decreased rapidly during ventricular
AUTHORS: W. E. Hoffman, C. Paisansathan, G. Weinberg fibrillation. Bupivacaine significantly reduced the rate of decrease in
AFFILIATION: Univ of Illinois at Chicago, Chicago, IL. pH during fibrillation by a factor of four. This may be related to the
ability of bupivacaine to inhibit glycolysis or to inhibit myocardial
INTRODUCTION: Ventricular fibrillation is associated with contractility. At the same time, the rate of decrease in PmO2 was not
myocardial ischemia, tissue hypoxia and acidosis. It is likely that the changed by bupivacaine. This may be due to the uncoupling of oxygen
rapid decrease in myocardial tissue pH during fibrillation can lead to utilization and adenosine triphosphate production produced by
irreversible tissue injury. Bupivacaine cardiac toxicity might also be bupivacaine in the mitochondria.
exacerbated by worsening tissue acidosis during fibrillation. The
purpose of this study was to measure the rate of decrease in myocardial Myocardial Tissue PO2 and pH during Fibrillation (* = P < 0.05 vs. sham)
tissue oxygen pressure (PmO2) and pH during fibrillation in dogs Basline PmO2 Rate of PmO2 Time of pH Rate of pH
treated with 10 mg/kg bupivacaine intravenous or dogs treated with PmO2 decrease
Time of PmO2
decrease
Baseline pH
decrease decrease
decrease (min) pH decrease
saline. (mmHg) (mmHg) (mmHg/min) (min) (units/min)
METHODS: These studies received animal care committee approval. Sham
49±11 41±11 3.0±1.5 15±5 7.32±0.02 0.42±0.13 6.2±3.3 0.08±0.02
Twelve dogs were anesthetized with propofol, their tracheas intubated (n = 5)
and lungs ventilated with 1.5% end tidal isoflurane with an inspired Bupivacaine
50±17 49±16 2.5±0.9 22±5 7.28±0.10 0.31±0.08 13.8±5.1* 0.02±0.01*
oxygen content of 30%. The chest was opened and a paratrend fiber (n = 7)
optic probe that contains sensors to measure PmO2, pH and temperature

was inserted into myocardial tissue at a depth of 6 mm in the left
ventricle within the distribution of the left anterior descending artery.
The probe is 0.5 mm in diameter and was introduced into the tissue
using a 21 gauge angiocatheter. Myocardial temperature was
maintained at 38oC. After a 45 minute equilibration period, baseline
measures of arterial blood pressure, heart rate, arterial blood gases and
pH and myocardial tissue PmO2 and pH were measured. Each dog
received either 10 mg/kg bupivacaine over 2 minutes (n = 7) or a sham
saline treatment (n = 5). Three minutes later, ventricular fibrillation was
initiated by touching a 9 volt battery to the heart. The rate of decrease in
PmO2 and pH during ventricular fibrillation was measured in each dog.
RESULTS: Baseline blood pressure, heart rate, blood gas, myocardial
PO2 and pH were similar in the two groups of dogs before ventricular
fibrillation (table 1). There was a rapid decrease in PmO2 during
fibrillation, and the rate of decrease was not different between sham and
bupivacaine treated dogs. Tissue pH also decreased during fibrillation,
S-23 2003; 96; S-1–S-293
S-22
CLONING AND CHARACTERIZATION OF THE RAT
ALPHA1A-ADRENERGIC RECEPTOR GENE PROMOTER:
DEMONSTRATION OF CELL-SPECIFICITY AND
REGULATION BY HYPOXIA
AUTHORS: G. Michelotti, M. P. Smith, D. A. Schwinn
AFFILIATION: Duke University Medical Center, Durham, NC.
Recent studies revealed an important and distinct role for the cardiac 1a-
adrenergic receptor. Surprisingly, given its importance in myocardial
ischemia/reperfusion, hypoxia, hypertrophy, and frequent use of rat
cardiomyocyte model systems, the rat 1aAR gene promoter has not been
characterized. We isolated and characterized 4.1Kb of rat 1aAR 5’-
regulatory sequence, identifying both a proximal and distal transcription
initiation site located 131bp and 1.9Kb upstream from the initiation
methionine, respectively. The proximal promoter, described here, lacks
typical TATA or CCAAT boxes, but contains cis-elements for multiple
myocardial-relevant nuclear regulators including Sp1, GATA, and
CREB. Additionally, the proximal promoter appears to govern cell-
specific basal expression as well as 1aAR transcription with hypoxic
stress. Under normoxic conditions, deletion reporter constructs revealed
the presence of several independent enhancer regions between -550/-48
important for basal transcription. Further analysis under hypoxic
conditions reveals multiple, independent regions are important for
hypoxia-specific transcriptional activity in myocardium, with the -819/-
326 region conferring robust hypoxia responsiveness. Gel shift analysis
across this region reveals a hypoxia-mediated shift located within -437/
-389, which is independent of direct HIF binding. This binding activity
was further defined to two 14bp stretches of sequence, previously
undescribed for hypoxia responsiveness. These new findings for the
1aAR gene lay a critical foundation for future studies designed to
elucidate specific 1AR-mediated pathways involved in distinct
myocardial pathologies.
S-23
EMPLOYING DOPEXAMINE AS A USEFUL AGENT TO reduced mean pulmonary arterial pressure in endotoxemic sheep (23±1
REVERSE THE ARGININE VASOPRESSIN-ASSOCIATED vs. 27±1.5; P < 0.05), mean arterial pressure decreased compared with
DECREASE IN OXYGEN DELIVERY DURING OVINE baseline.
ENDOTOXEMIA DISCUSSION: During ovine endotoxemia, concomitant infusion of
AVP and low doses DPX reversed the hyperdynamic circulation and
AUTHORS: M. Westphal, H. Stubbe, F. Daudel, H. Van Aken, M. improved DO2. Although high dose DPX also improved the pulmonary
Booke, H. G. Bone circulation, the aggravation of systemic hypotension might limit its
AFFILIATION: Department of Anaesthesiology and Intensive Care, therapeutic use.
University of Muenster, Muenster, Germany. REFERENCES:
1. Anesthesiology 2002; 96:576-582
INTRODUCTION: Arginine vasopressin (AVP) is increasingly used 2. Chest 2001; 120: 989-1002
for hemodynamic support of septic patients (1). Via reflex mechanisms,
AVP reduces cardiac index and in proportion oxygen delivery (2). This Effects of vasopressin and dopexamine on hemodynamics and oxygen delivery
could be challenging during sepsis, where tissue oxygen requirements parameter state baseline sole AVP AVP+DPX 1 AVP+DPX 5 AVP+DPX 10
are increased. The purpose of this prospective, controlled study was to health 101±2 112±3# 109±2# 99±4§ 95±3#§
determine the efficacy of dopexamine (DPX) as an adjunct to AVP MAP
endotoxemia 86±2* 105±4# 103±4# 94±4#§ 80±3*§
infusion.
health 5.9±0.4 3.9±0.3# 5±0.3#§ 5.7±0.3§ 7±0.4#§
METHODS: Healthy ewes instrumented for chronic study received a CI
endotoxemia 7.8±0.4* 4.6±0.4 5.1±0.3 6.6±0.5§ 8±0.5§
continuous AVP infusion (2.4 U·h-1). One hour later, DPX was
health 842±66 475±38# 607±46#§ 707±39§ 851±61§
additionally administered at incrementing doses (1, 5, 10 g·kg-1·min-1; DO2
endotoxemia 1073±49* 613±44*# 670±36# 863± 6§ 1012±74*§
each dose for 30 minutes). Then, drug infusions were stopped. After a
AVP=arginine vasopressin [2.4 U·h-1]; DPX=dopexamine [µg·kg-1·min-1]; MAP=mean arterial
24-hour period of recovery, endotoxin (salmonella typhosa, 10 ng·kg- pressure [mmHg]; CI=cardiac index [L·min-1·m-2]; DO2=oxygen delivery [mL·min-1·m-2]
1
·min-1) was continuously infused to induce and maintain a hypotensive-
hyperdynamic circulation. After 16 hours of endotoxemia, AVP and *P < 0.05 health vs. endotoxemia; #P < 0.05 vs. baseline; §P < 0.05 vs. sole AVP
DPX were given as described previously. Since the same animals were
studied in a healthy and a septic state, they served as their own controls
(n=7 per group). For statistical analysis, a two-way analysis of variance
with a Student-Newman-Keuls post hoc correction was used. Data are
expressed as mean±SEM.
RESULTS: The AVP-associated increase in mean arterial pressure was
associated with a reduction in cardiac index, thereby decreasing oxygen
delivery in both health and endotoxemia. In addition, pulmonary
vascular resistance index increased in endotoxemia (202±16 vs.
159±13; P < 0.05). Low doses DPX (1 and 5 g·kg-1·min-1) reversed the
changes in cardiac index and pulmonary vascular resistance index and
increased oxygen delivery. While high dose DPX (10 g·kg-1·min-1)
2003; 96; S-1–S-293 S-25
S-24
THE EFFECT OF GP683, A NOVEL ADENOSINE KINASE maximum increase in HR and RSNA to maximum reduction of MAP
INHIBITOR, ON HEMODYNAMIC AND SYMPATHETIC were significantly reduced by G1.0 (HR/MAP 0.26±0.27, RSNA/MAP
OUTFLOW IN NERVE-INTACT AND BARORECEPTOR- 1.64±0.69) in comparison with SNP (1.55±0.68, 6.22±2.97,
DENERVATED RABBITS respectively). There were dose-dependent and significant reductions of
all variables in the baro-denervated group even at 30min with G (MAP
AUTHORS: T. Fujisawa, S. Sumita, K. T. Benson, J. D. Kindscher, H. 84.9±11.2%*, 59.7±12.7%*, HR 94.8±3.9%, 89.9±5.8%*, and RSNA
Goto 95.1±2.3%, 82.7±7.8%* for G1.0 and 2.0, respectively). The solvent
AFFILIATION: Anesthesiology, University of Kansas Medical produced no changes in MAP, HR or RSNA.
Center, Kansas City, KS. DISCUSSION: Since both arterial and cardiopulmonary baroreflexes
were eliminated in the baroreceptor-denervated group, decreased RSNA
INTRODUCTION: It has been reported that continuous i.v. infusion indicates that GP683 directly depressed the central sympathetic nervous
of GP683, one of the adenosine kinase inhibitors, decreased desflurane system. The significant reduction of the ratios of maximum increase in
minimal alveolar concentrations in dogs(1). The purpose of the current HR and RSNA to maximum reduction of MAP indicates that GP683
study was to evaluate the effects of GP683(G) on mean arterial attenuates both cardiac and sympathetic baroreflex sensitivity.
pressure(MAP), heart rate(HR), renal sympathetic nerve Therefore, reduction of sympathetic outflow and attenuated baroreflex
activity(RSNA) and baro-sensitivity, using nerve-intact and sensitivity are contributing factors to GP683-induced arterial
baroreceptor-denervated rabbits. hypotention. These sustained effects of GP583 on the cardiovascular
METHODS: New Zealand white rabbits were anesthetized with i.v. and sympathetic nervous systems suggest that GP683 administered by a
urethane, tracheotomized and ventilated. The left renal sympathetic bolus injection inhibits adenosine kinase continuously so that
nerves were isolated, and RSNA was recorded along with MAP and endogenous adenosine concentrations remain elevated.
HR. In the baroreceptor-denervated group, all animals received a Further study is necessary to elucidate whether a single administration
combined denervation of carotid sinus, aortic and vagal nerves. G was of GP683 produces prolonged anesthesia sparing action in addition to
dissolved in solvent 5% dimethyl sulfoxide(DMSO). The animals were hemodynamic and sympathetic depressant actions.
divided into 6groups (n=6 each): G0.5, 1.0 (0.5 and 1.0mg/kg) and REFERENCES:
SNP(40g/kg) for the intact group, and G1.0, 2.0 (1.0 and 2.0mg/kg) and (1) Anesth Analg 85 : 675 - 680, 1997
5%DMSO for the denervated group. Each agent was injected i.v. as a
bolus and all variables were continuously recorded for the next 30 min.
All data (mean±SD) were expressed as percent changes from control
values, and ANOVA followed by Sceffe’s procedure was used for
statistical analysis. *P<0.05 was considered statistically significant.
RESULTS: In the nerve-intact group, maximum reductions of MAP
occurred within 1min (80.9±5.3%*with SNP, 84.5±6.1%*with G0.5 and
71.2±6.2%*with G1.0, respectively). MAP did not return to baseline
values and remained slightly but significantly low with G0.5 and 1.0.
After brief but significant baroreflex-mediated increases in RSNA and
HR, they returned to baseline values in all groups. The ratios of
S-25
DIRECT EFFECTS OF ROPIVACAINE AND BUPIVACAINE cardiopulmonary baroreflexes were eliminated. The initial increase of
ON SYMPATHETIC NERVE ACTIVITY IN RABBITS RSNA with B may correspond to the seizure phase of B. Thereafter B
significantly decreased RSNA even after its infusion was discontinued.
AUTHORS: S. Sumita, T. Fujisawa, G. K. Unruh, K. T. Benson, H. On the other hand, RSNA did not change appreciably with R.
Goto Therefore, this may be one of the reasons why ropivacaine has less
AFFILIATION: University of Kansas Medical Center, Kansas City, cardiotoxicity as compared with bupivacaine.
KS. REFERENCES:
1) Anesth Analg. 2001;92:37-43, 2) Anesth Analg. 2000;91:1489-92.
INTRODUCTION: Ropivacaine (R) has been reported to cause less
cardiovascular depression than equivalent concentrations of
bupivacaine (B) (1,2). The reason may be, in part, related to their
different degrees of depressive action to the central sympathetic
nervous system. In the present study, we compared the direct effects of
R and B on sympathetic nerve activity using baro-denervated rabbits.
METHODS: Twelve New Zealand white rabbits were anesthetized
with 1 g/kg urethane iv, and anesthesia was maintained with continuous
infusion of urethane (200 mg/kg/hr). All animals had a combined
denervation of bilateral carotid sinus, aortic and vagal nerves to
eliminate both arterial and cardiopulmonary baroreflexes. The animals
were divided into two groups: R group and B group (n=6 for each
group). In the R group, the rabbits received R infusion at a rate of
0.25mg/kg/min for 10 min. In the B group, they received B infusion at
the same rate for 10 min. Heart rate (HR), mean arterial pressure (MAP)
and renal sympathetic nerve activity (RSNA) were continuously
recorded. All data (% change) were analyzed by ANOVA and Fisher’s
PLSD. *P<0.05 was considered significant.
RESULTS: Time course % changes of RSNA are shown in figure. In
the B group, RSNA showed a bi-phasic pattern. RSNA initially
increased significantly (the highest value; 167.7 ± 25.1%*, mean ± SD,
at 4 min) and then, it started to decrease and remained significantly low
(the lowest value; 70.1 ± 14.0%* at 15 min). In the R group, RSNA also
showed the similar bi-phasic pattern, but there were no significant
changes from the control value except at the 3 min measurement point
(119.1 ± 15.0%*). Both MAP and HR decreased gradually and
significantly during infusion in both groups.
DISCUSSION: Changes of RSNA were due to the direct effect of R
and B on the central sympathetic nervous system since both arterial and
S-27 2003; 96; S-1–S-293
S-26
HEMODILUTIONAL ANEMIA CAUSES TRANSIENT RESULTS: Hemodilution resulted in a final hemoglobin concentration
CEREBRAL HYPOXIA AND INCREASED CORTICAL NNOS of 51.0 ± 1.2 g.L-1 while MAP was maintained near baseline values
MRNA LEVELS. (68.9 ± 2.8 mmHg). Blood gases did not change significantly (pH 7.40
± 0.03, PaCO2 34.5 ± 1.8 and PaO2 125.5 ± 10.4 mmHg). PBrO2
AUTHORS: G. T. Hare1, C. Mazer1, W. Mak2, K. M. Hum1, A. Barr1, decreased transiently, from 17.3 ± 4.1 to 14.4 ± 4.1 mmHg during
A. J. Baker1 hemodilution (p< 0.01), before returning to baseline after an additional
AFFILIATION: 1St. Michael's Hospital, University of Toronto, 10 minutes. Normalization of PBrO2 occurred coincident with the
Toronto, ON, Canada, 2Biotechnolgy Center for Applied Research and maximal increase in CBF, 10 minutes after completion of hemodilution.
Training, Toronto, ON, Canada. After 3 hours, cerebral cortical nNOS mRNA levels were significantly
higher in the anemic group relative to controls (2.6 ± 0.6 vs 1.2 ± 0.2 ng
INTRODUCTION: Cerebral hypoxia may contribute to anemia RT-PCR product per ng total RNA, respectively, p<0.05). No
induced impairment in cognitive function (1). The characteristic differences in IL-1 or eNOS, mRNA were detected.
increase in cerebral blood flow (CBF) observed with anemia may DISCUSSION: These data support the hypothesis that acute
represent a compensatory response directed toward augmenting hemodilutional anemia caused transient cerebral hypoxia which
cerebral oxygen delivery. Inhibition of neuronal nitric oxide synthase resolved once the maximal increase in CBF was achieved. The increase
(nNOS) activity partially impairs this response, implicating nNOS as an in cerebral cortical nNOS mRNA levels provide additional evidence
important mediator of CBF during anemia. (2). Although increased that anemia resulted in cerebral hypoxia. Increased nNOS mRNA gene
cerebral nNOS mRNA has been demonstrated during hypoxia (3), such expression may be involved in the mechanism by which increased CBF
upregulation has not been demonstrated during anemia. This study tests is maintained during chronic anemia.
the hypothesis that acute hemodilutional anemia causes cerebral REFERENCES:
hypoxia which triggers an increase in cerebral nNOS mRNA levels, 1) Anesthesiology 92:1646, 2000,
supporting a role for an nNOS mediated increase in CBF. 2) J Cereb Blood Flow Metab 20: 220, 2000,
METHODS: Anesthetized ventilated rats underwent tail artery and 3) J Neurosci Res 49: 89, 1997. (CAS, JP Bickell Foundation and PSI
jugular vein cannulation. Mean arterial pressure (MAP) was Support)
continuously monitored. Blood gas analysis ensured maintenance of
normocapnea and normoxia. Polarographic oxygen sensitive
microelectrodes and laser doppler flow probes, placed using stereotaxic
coordinates, measured cerebral tissue oxygenation (PBrO2) and CBF,
respectively. Hemodilutional anemia (n=7) was achieved by exchanging
30 ml.kg-1 of blood with pentastarch over 10 minutes. Control animals
did not undergo hemodilution (n=6). Cerebral cortical samples were
harvested after 3 hours, snap frozen, total RNA extracted, and RT-PCR
performed using primers for IL-1, eNOS and nNOS. Quantitation of
RT-PCR product was performed using a digital imaging system.
Statistical significance was assessed using Wilcoxon rank sum and
signed rank tests (Mean ± SEM).
S-27
EFFECTS OF SODIUM THIOPENTAL AND METHYL- the treatment with MPS, as the LDH activity reached 71 ± 9.6 % of
PREDNISOLONE DURING OXIDATIVE STRESS IN HUMAN maximum (n = 9, P < 0.05) and the formation of blebs was potentiated.
NEURONAL SH-SY5Y CELLS DISCUSSION: The neuroprotective effect of STP during H2O2 -
induced oxidative stress is consistent with its ability to scavange free
AUTHORS: J. Wojtczak radicals (2). However, a potentiation of the oxidative injury by MPS is
AFFILIATION: University of Rochester, Rochester, NY. unexpected as glucocorticoids also have an antioxidant action (3). It is
possible that this potentiation is caused either by MPS-induced
INTRODUCTION: Hypothermia is a major neuroprotectant during inhibition of glucose uptake into neurons or by stimulation of
deep hypothermic circulatory arrest (DHCA). However, as brain glutamate-related Ca2+ signaling (4). The routine use of glucocorticoids
cooling is an imperfect process, several pharmacologic adjuvants are during DHCA may be detrimental as their neurotoxic potential may
also frequently used in an attempt to improve neuroprotection during outweigh their benefits.
DHCA (1).Oxidative stress occurring during brain reperfusion, plays a REFERENCES:
major role in ischemic brain injury. In this study we have compared the 1. Cardiothor Vasc Anes 12, 591, 1998
effects of sodium thiopental and the glucocorticoid methylprednisolone 2. Anesthesiology 92, 764, 2000
on hydrogen peroxide (H2O2)-induced cell death in cultured human 3. Acta Anaesthesiol Scand 42, 4, 1998
neuronal SH-SY5Y cells. 4. J Neurocytology 29, 439, 2000
METHODS: Necrotic cell death was assessed by measuring the
enzyme activity of lactate dehydrogenase (LDH) released from the
cytosol of cultured human neuronal SH-SY5Y cells into the
supernatant. The release occurs upon damage of the plasma membrane.
The maximum amount of releasable LDH enzyme activity was
determined by the lysis of all cells with a detergent. Cell morphology
was monitored using phase contrast microscopy and time lapse
photography. The LDH enzyme activity was measured in the
supernatants of cells incubated for 3 hours in the control medium with
or without either 1 mM sodium thiopental (STP) or 0.3 mM
methylprednisolone (MPS). During the last hour, oxidative cell injury
was induced by exposure to 1 mM H2O2 and the LDH enzyme activity
in the supernatants was then measured.
RESULTS: Incubation of neurons in the control medium for 3 hours
induced only a minimal cell death (LDH activity 8.7 ± 1.1 % of
maximum). Exposure to H2O2 produced a large increase in the LDH
activity in the supernatants (53 ± 6.2 % of maximum, n = 9, P < 0.05)
and a development of plasmalemmal blebs. The LDH release and the
formation of blebs was significantly reduced by the treatment with STP
(LDH activity 37 ± 5.1 % of maximum, n = 9, P < 0.05). However,
H2O2-induced cell death was not reduced and was actually enhanced by
2003; 96; S-1–S-293 S-29
S-28
EFFECT OF SELEGILINE ON THE CONTRACTILE AND selegiline against ACh- and KCl-induced contractions were 120 ± 30 M
PHOSPHATIDYLINOSITOL RESPONSES OF RAT TRACHEA and 80 ± 20 M respectively. Basal and ACh-induced IP1 accumulation
were 2.51 ± 0.15 and 4.25 ± 0.13 Bq, respectively, and selegiline at a
AUTHORS: M. Yoshimura, O. Shibata, M. Yamaguchi, M. Saito, T. dose of 1000 M attenuated ACh-induced IP1 accumulation (2.87 ± 0.13
Makita, K. Sumikawa Bq).
AFFILIATION: Nagasaki University School of Medicine, Nagasaki, CONCLUSIONS: Selegiline inhibited ACh- and KCl-induced
Japan. contractile responses and it attenuated ACh-induced IP1 accumulation.
These results suggest that selegiline inhibits contractile responses
Selegiline, monoamine oxidase (MAO) -inhibitor, is widely used for through the inhibition of voltage-operated Ca++ channels and the PI
Parkinson’s disease and possibly for Alzheimer’s disease. The patients response. Thus selegiline would be safe for the patients with asthma.
treated with selegiline before surgery are increasing in number because Reference: 1. No To Shinkei 1998;50:1093-9
the treatment of their diseases is increasing as the number of people
with the diseases increases. On the other hand, bronchial hyper-
responsiveness and asthma are prevalent among elderly population.
Selegiline is reported to cause a transient intracellular influx of Ca++ in
cultured neuronal cells [1]. Since intracellular Ca++ is partly regulated
by phosphatidylinositol (PI) response and Ca++ is important for smooth
muscle contractions, selegiline may affect the airway smooth muscle
tension. However, the effects of selegiline on patients with asthma are
not fully understood. Thus, we examined the effects of selegiline on
acetylcholine (ACh)-induced contractile and PI responses of rat trachea.
METHODS: The studies were conducted under guidelines approved
by the Animal Care Committee. Twenty male Wistar rats weighing 250-
350g were used for the experiments. The rats were anesthetized with
pentobarbital and their tracheas were rapidly isolated. The trachea was
cut into 3-mm-wide ring segments or 1-mm-wide slices. Tracheal slices
were incubated with [3H]myo-inositol. ACh (3 M in a final
concentration) or KCl (40 mM in a final concentration) was added to
induce tracheal contraction, and ring relaxation was induced by
additions of selegiline from 0 M to 1000 M in final concentrations. The
[3H] inositol monophosphate (IP1), a degradation product of PI
response, was measured with a liquid scintillation counter. Data were
expressed as mean ± SE. Statistical significance (P < 0.05) was
determined using ANOVA.
RESULTS: Selegiline attenuated ACh- and KCl-induced tracheal ring
contraction dose-dependently. Fifty-percent inhibitory doses (ID50) of
S-29
DOES READ’S REBREATHING TECHNIQUE OVER- (3), but its continued use appears to be based on misplaced confidence
ESTIMATE THE VENTILATORY RESPONSE TO CO2? in a few, very small studies performed before 1991 (1,2). When results
of all studies are taken into account, rebreathing overestimates the
AUTHORS: J. J. Pandit ventilatory CO2 response by a mean of about 50%. This overestimate
AFFILIATION: John Radcliffe Hospital, Oxford, United Kingdom. would have a profound effect on the interpretation of many clinical
studies. Rebreathing techniques should be used with caution in drug or
INTRODUCTION: Read (1967) described a rebreathing technique to anesthetic studies which aim to assess ventilatory responses to CO2.
measure the central chemosensory ventilatory response to CO2 (1). REFERENCES:
Some studies since then have confirmed that the value obtained using 1.Aust Ann Med 1967; 16: 20-32.
this method is in agreement with the alternative, steady state method 2.Resp Physiol 1991; 85: 97-110.
(2). However, other studies claim that the Read technique overestimates 3.J Physiol 1989; 411: 367-377.
the response (3). Read‘s method is still widely used to assess the 4.Br J Anaesth 1995; 75: 394-8.
respiratory effects of many anesthetic drugs (4), so it is important to 5.Br Med J 1998; 316: 129.
know whether it provides accurate results. In the absence of a single, 6.Br J Anaesth 1996; 76: 747-8.
very large study comparing steady state and rebreathing methods, one
approach to resolving this issue is to conduct a quantitative review
(meta-analysis) of published studies.
METHODS: A MEDLINE-assisted search was conducted,
supplemented by use of reference lists, to obtain all papers which
compared the ventilatory response to CO2 in humans using rebreathing
(Sr) with steady state (Ss) methods. All studies gave their results for Sr
and Ss in l/min/mmHg. A value of Sr/Ss and confidence interval (95%
CI) was calculated for each study. These values were combined by
calculating the mean, weighted for study size (5). Confidence interval
analysis was used to assess whether the final result was statistically
significant.
RESULTS: A total of 11 relevant publications were found. The largest
study used 12 subjects. Sr/Ss ranged from 0.86 to 2.82. The majority (9/
11) studies yielded a mean Sr/Ss greater than 1, but in 8 of these, the
95% CI included an Sr/Ss value of 1, suggesting that these 8 studies
could not individually detect with confidence any difference in the two
methods. Combining the results showed a weighted mean Sr/Ss of 1.56
(95% CI 1.13 to 1.99), which was statistically significant (P < 0.05; Fig
1).
CONCLUSIONS: Read‘s method continues to be used in clinical,
anesthetic and physiological studies (6). There are a number of
theoretical arguments which question the validity of Read‘s technique
S-31 2003; 96; S-1–S-293
S-30
LEFT ATRIUM COMPUTER MODEL THAT ACCURATELY RESULTS: The model produces, in physiologic units, pressure
SIMULATES PRESSURE, FLOW, AND VOLUME,INCLUDING (including "v’ and "a’ waves), volume, and flow characteristic of in
MASS EFFECT AND STARLING'S LAW. vivo data. Validation was performed by generating Frank-Starling
curves of left atrial stroke volume as a function of preload. The
AUTHORS: A. M. Gust1, R. H. Small2 relationship described by the model, under conditions of constant
AFFILIATION: 1The Ohio State University College of Medicine, afterload, was SV=0.4185*Preload+0.0788mL. Yamaguchi et. al.
Columbus, OH, 2The Ohio State University Dept. of Anesthesiology, measured 28 patients with ischemic heart disease and found
Columbus, OH. SV=0.48*Preload-1.3mL.5 The linear relationship between stroke
volume and preload indicates the simulation of Frank-Starling behavior.
INTRODUCTION: The goal was the production of a circuit model of DISCUSSION: An interesting consequence of the time-varying
the left atrium that could be modeled in PSpice circuit simulation elastance model in coupling pressure and volume is the dependence of
software. The ability of the circuit to accurately generate pressure, flow, atrial conduit, reservoir and pump function on loading conditions. Thus,
and volume waveforms in physiologic units is the source of its the frequency-dependent impedance network plays a role in
flexibility and versatility. The presence of Frank-Starling behavior determining the optimal performance of the left atrium in filling the left
validated the ability of the model to compensate for varying volume ventricle. The model succeeds in providing accurate representation of
loading conditions. This indicates its feasibility for incorporation into physiologic behavior while maintaining flexibility for incorporating
other circulatory and closed-system models. Many current models effects of pathologic conditions or pharmacologic interaction.6
describe physiologic performance but a lack of flexibility detracts from REFERENCES:
their use as modular components exploring large-scale circulatory 1
Circulation Research 61 (1987): 209-19.
system behavior. 2
American Journal of Physiology 268 (1995): H476-89.
METHODS: The left atrium was modeled in OrCAD PSpice 3
simulation software. The atrium was characterized by a time-varying Japanese Circulation Journal 61 (1997): 1015-20.
4
elastance independent of loading conditions.1 This is governed by IARS 74th Congress 90 (2S) Feb. (2000): Supplement.
5
E(t)=Pla(t)/[Vtot(t)-Vresid(t)], where E(t) is the time-varying elastance, Japanese Circulation Journal 51 (1987): 1001-9.
6
and Pla(t), Vtot(t), and Vresid(t) are the time-varying left atrial pressure, Circulation 89 (1994): 1829-38.
total chamber volume, and residual volume, respectively. Values for
these parameters were interpreted from Alexander's in vivo
measurements of 12 anesthetized canines. The model describes the
pulmonary veins and capillaries as a pressure source coupled to an R-L-
C impedance network.2 Included in the impedance network is an
inductance, Lpv, simulating the mass effect of blood recoil upon
contraction. The inflow is then related to the difference in pressures
between the pulmonary veins and the left atrial pressure.3 Volume of the
chamber is determined by integration of the net flow as in LaMack et.
al.4 The outflow resulting from atrial systole contributes both to
ventricular filling, represented by Qmv, and return flow to the
pulmonary veins, Qpv.
S-31
EFFECTS OF A SILDENAFIL ANALOG; UK343-664, ON A
PORCINE MODEL OF ACUTE PULMONARY HYPER-
TENSION
AUTHORS: F. Urdaneta, N. Valdez, M. Bonnel, M. Palacios, D.
Kirby, E. Lobato
AFFILIATION: University of Florida, Gainesville, FL.
INTRODUCTION: Sildenafil has been associated with pulmonary
vasorelaxation 1-3. A more potent sildenafil analog , UK343-664, has
been developed but it effects in vivo have not been studied. This study
evaluated the effects of UK 343-664 during acute pulmonary
hypertension.
METHODS: 14 adult swine were anesthetized with 1 MAC isoflurane
and mechanically ventilated with an Fi02 of 100%. End tidal C02 was
maintained between 32- 36 mm Hg. Micromanometer tipped catheters
were placed in the ascending aorta, pulmonary artery and right
ventricle. Pulmonary flow was measured with a perivascular probe
using transit time ultrasound. Pulmonary hypertension was induced
with a continuous infusion of the thromboxane analog U46619 .
Animals were randomized to two groups. Group 1 (n=9) received 500
mcg of UK343-664 IV over 2 minutes. Group 2 (n=5) served as control.
Data were recorded continuously for 60 minutes. Statistical analysis
were performed with ANOVA and t tests. A p <0.05 was considered
significant
RESULTS: Pulmonary hypertension was achieved in all animals. The
administration of UK343-664 was associated with a significant
decrease in pulmonary artery pressure (30.3%; p<0.05), and pulmonary
vascular resistance (42%;p<0.05), without systemic vasodilatation. This
effects were partially maintained at 30 minutes (17.3% and 39%
decrease respectively; p<0.05).
CONCLUSIONS: The administration of UK 343-664 was associated
with significant vasodilatation without systemic effects. This may
represent a significant advance in the treatment of acute pulmonary
hypertension. It's potential clinical implications need to be explored
2003; 96; S-1–S-293 S-33
S-32
PRETREATMENT WITH VOLATILE ANESTHETICS demonstrated: 1) that neither PMN alone nor PAF alone caused cardiac
PREVENTS NEUTROPHIL-INDUCED CONTRACTILE dysfunction, and 2) that, although Glib alone did not alter PMN-induced
DYSFUNCTION IN ISOLATED RAT HEARTS: LACK OF cardiac dysfunction, it prevented the protection conferred by the
ROLE FOR KATP CHANNELS specific KATP channel opener pinacidil.
RESULTS: PAF-activated PMN caused marked, persistent reductions
AUTHORS: G. Hu, M. Salem, G. J. Crystal (>50%) in LVDP (Figure). Pretreatment with either Iso or Sevo
AFFILIATION: Advocate IL Masonic Med Ctr & Univ IL Col Med, abolished this effect. Glib did not alter this action of the anesthetics.
Chicago, IL. DISCUSSION: 1) The volatile anesthetics Iso and Sevo had a profound
preconditioning effect on the heart; 1 MAC of each anesthetic was
INTRODUCTION: Volatile anesthetics have been shown to adequate to completely abolish the ability of activated PMN to cause
precondition the myocardium against functional depression and cardiac dysfunction. 2) The inability of Glib to blunt this effect suggests
infarction following ischemia-reperfusion (1). Neutrophil (PMN) that it was independent of the KATP channels in the myocytes and
activation, adherence, and release of oxygen free radicals and coronary vasculature.
proteolytic enzymes are known to play a major role in reperfusion REFERENCES:
injury. Our previous study suggested that an ability of volatile 1. Anesthesiology 1997;87:361-370.
anesthetics to inhibit PMN-endothelium interactions may be involved in 2. Anesth Analg 2002;94:849-56.
their cardioprotective effects (2). The present study was conducted in
isolated crystalloid-perfused rat hearts to test the hypothesis that
pretreatment with isoflurane (Iso) or sevoflurane (Sevo) can prevent the
cardiac dysfunction caused by PMN activated with platelet activating
factor (PAF). Because KATP channels have been implicated in the
preconditioning effects of volatile anesthetics in vivo, we evaluated the
role of these channels using the KATP channel antagonist glibenclamide
(Glib).
METHODS: Studies were performed in 56 isolated, paced rat hearts.
The hearts were perfused at constant flow with Kreb’s buffer at a rate
sufficient to achieve a perfusion pressure of 70 mmHg. Left ventricular
developed pressure (LVDP) served as an index of myocardial
contractility. The basic experimental protocol consisted of 10 min
administration of PMN-PAF mixture followed by 30 min recovery. The
intracoronary concentration for PMN and PAF were 3 x 105 PMN/ml
and 1 nM, respectively. The main experimental groups were: 1) control
group: no pretreatment; 2) pretreatment with Iso; 3) pretreatment with
Sevo; 4) pretreatment with Iso during Glib (10 M); 5) pretreatment with
Sevo during Glib. Pretreatment of the heart consisted of administration
of 1 MAC Iso or Sevo for 15 min followed by 10 min washout prior to
administration of PMN-PAF. Additional validation studies
S-33
PROPOFOL INCREASES CONTRACTILITY DURING propofol (10-4 M) further increased (p < 0.05) twitch contraction by 38
ENDOTHELIN-1 AND ANGIOTENSIN II RECEPTOR ± 12% and 159 ± 24%, respectively, whereas peak [Ca2+]i only
ACTIVATION IN RAT CARDIOMYOCYTES increased by 17 ± 8% and 14 ± 11%, respectively. Propofol did not alter
Tp and T50r for [Ca2+]i or shortening.
AUTHORS: T. Shiga, P. A. Murray, D. S. Damron DISCUSSION: These results demonstrate the predominance of a Ca2+
AFFILIATION: Cleveland Clinic Foundation, Cleveland, OH. sensitizing action of ET-1 on cardiomyocyte function, whereas Ang II
enhances both [Ca2+]i and myofilament Ca2+ sensitivity. These data
INTRODUCTION: Myocardial levels of endothelin (ET) and suggest that distinct signaling pathways are involved in the ET-1- and
angiotensin (Ang) are elevated in patients with hypertension and Ang II-induced cardiomyocyte inotropy. Propofol further increased
congestive heart failure. Activation of ET-1 and Ang II receptors results contractility during ET-1 and Ang II receptor activation, primarily via
in stimulation of parallel, yet divergent, signaling pathways. We an increase in myofilament Ca2+ sensitivity.
previously demonstrated a propofol-induced potentiation of 1A- REFERENCES:
adrenoreceptor mediated increases in cardiomyocyte shortening via 1. Shiga et al, Anesthesiology 94:A-613, 2002
activation of a protein kinase C-dependent pathway (1). Our current
objectives were to identify the extent to which propofol alters ET-1 and
Ang II receptor-mediated cardiomyocyte inotropy.
METHODS: All procedures were approved by the Institutional Animal
Care and Use Committee. Freshly isolated ventricular myocytes were
obtained from adult rat hearts. Intracellular free Ca2+ concentration
([Ca2+]i) and myocyte shortening were simultaneously measured using
fura-2 (340/380 ratio) and video-edge detection, respectively, in
individual field-stimulated myocytes (28ºC). Statistical analysis was
performed using analysis of variance and Bonferroni t-test. Data are
reported as means ± SEM.
RESULTS: Resting cell length was 125 ± 5 m and baseline [Ca2+]i
was 120 ± 13nM. Cell shortening induced by field-stimulation resulted
in a twitch contraction that was 3.5 ± 0.4 m. Time to peak (Tp) [Ca2+]i
and shortening were 107 ± 3 and 197 ± 26 msec, respectively. Time to
50% return (T50r) to baseline [Ca2+]i and shortening were 176 ± 12
and 177 ± 12 msec, respectively. Addition of ET-1 (10-7M) increased (p
< 0.05) twitch contraction by 56 ± 17%, whereas peak [Ca2+]i only
increased by 11 ± 6%. Tp and T50r for [Ca2+]i and shortening were
unaltered by ET-1. In contrast, addition of Ang II (10-7M) increased (p
< 0.05) both twitch contraction by 180 ± 16% and peak [Ca2+]i by 55 ±
14%. Tp for [Ca2+]i and shortening and T50r for [Ca2+]i were not
altered by Ang II, but T50r for shortening decreased (p < 0.05) by 29 ±
7%. In the presence of ET-1 or Ang II-induced inotropy, addition of
S-35 2003; 96; S-1–S-293
S-34
CYCLIC GMP PHOSPHODIESTERASE INHIBITION AND 5
M) , isoproterenol (10-6M) increased cAMP (CON: 3.0±0.7 to 4.0±0.4
UNCOUPLING OF BETA-ADRENERGIC RESPONSES IN RENAL pmol /105 cells; 1K1C: 5.5±1.1 to 8.4±1.8 pmol /105 cells) without
HYPERTENSION-INDUCED CARDIAC HYPERTROPHY changing percent cell shortening (CON: 5.2±0.3% to 4.7±0.3%; 1K1C:
4.7±0.5% to 4.8±0.5%) in both groups.
AUTHORS: J. Tse, S. Zhang, P. M. Scholz, R. Rodriguez, H. R. Weiss DISCUSSION: The results show that the renal hypertension-induced
AFFILIATION: UMDNJ-Robert Wood Johnson Medical School, New cardiac hypertrophic rabbits had decreased cardiac contractile responses
Brunswick, NJ. to -adrenergic stimulation. Furthermore, -adrenergic-induced contractile
responses and cAMP production were uncoupled in the hypertrophic
INTRODUCTION: It has been shown that negative metabolic effects cardiac myocytes. Inhibition of cGMP degradation by zaprinast blunted
of cGMP were altered in renal hypertension-induced cardiac the contractile functions without affecting cAMP production in control
hypertrophy in rabbits (1,2). We tested the hypotheses that inhibition of myocytes. This uncoupling effect of zaprinast seems similar to that of
cGMP degradation would decrease -adrenergic responses in cAMP renal hypertension-induced cardiac hypertrophy.
production and contractile function in isolated cardiac myocytes and REFERENCES:
these effects would be altered in the hypertrophic myocytes. (1) Res Exp Med 198:11-21, 1998,
METHODS: Freshly isolated ventricular myocytes were prepared from (2) Anesthesiol 97: (3A)A618, 2002
hearts of control (CON) and 1K1C (one-Kidney-one-Clip) renal
hypertensive hypertrophic rabbits (35 days postoperatively). Percent
cell shortening (PCS) was measured by a video edge detector. Myocyte
levels of cGMP and cAMP were measured. Myocytes were treated with
isoproterenol (ISO 10-8,-6 M) or selective cGMP phosphodiesterase
(PDE) inhibitor zaprinast (ZAP 10-5M) alone for 5 min or in
combination. ANOVA was used for statistical analysis. A value of p
<0.05 was accepted as significant. Data were presented as
Mean±S.E.M. (N=7)
RESULTS: Isoproterenol (10-6M) increased cAMP level(+117%)
(2.3±0.3 to 5.0±0.7 pmol /105 cells) and percent cell shortening (+33%)
(4.8±0.2% to 6.4±0.3%) (see Figure: * significantly different from the
Base value) in the control myocytes. In 1K1C myocytes, isoproterenol
(10-6M) increased cAMP (+55%) (4.9±0.8 to 7.6±1.4 pmol /105 cells)
without changing percent cell shortening (5.3±0.4% to 4.9±0.3%) (see
Figure: + significantly different from the CON-ISO-6 value). The basal
level of cAMP was higher in 1K1C than the control myocytes.
Zaprinast (10-5M) increased cGMP (CON:150±20 to 209±14 fmol /l05
cells; 1K1C: 182±23 to 233±24 fmol /l05 cells) and decreased percent
cell shortening (CON: 6.2±0.4% to 5.2±0.3%; 1K1C: 6.6±0.9% to
4.7±0.5%) in both groups. Furthermore, in the presence of zaprinast (10-
S-35
CARDIOPULMONARY BYPASS REDUCES THE MAC OF DISCUSSION: CPB caused a small (10%) but significant reduction in
ISOFLURANE IN THE RAT the MAC of isoflurane. This finding may explain why the isoflurane
requirements to maintain a constant bispectral index (BIS) in humans,
AUTHORS: H. Yang, H. M. Homi, B. E. Smith, H. P. Grocott when compared to pre-CPB, are decreased in the post-CPB period (3).
AFFILIATION: Duke University Medical Center, Durham, NC. The mechanism behind this reduction in MAC is not clear but may be
related to cerebral injury (ischemia) or inflammation-associated cellular
INTRODUCTION: The influence of cardiopulmonary bypass (CPB) swelling (of brain and possibly spinal cord).
on anesthetic requirements has been the subject of past investigations, REFERENCES:
but definitive conclusions have been affected by methodologic 1. Hall RI, et al. Anesthesiology 1990;73:249-255
limitations, lack of adequate controls, and other confounding 2. Neumeister MW, et al. Can J Anaesth 1997;44:1120-26
physiologic variables (1,2). Recently, clinical data has also suggested a 3. Lundell JC,et al. J Cardiothorac Vasc Anesth 2001;15:551-554
CPB-induced reduction in isoflurane requirements (3). The purpose of 4. Eger EI, et al. Anesthesiology 1965;26:756-63
this investigation was to determine the influence of CPB on the
minimum alveolar concentration (MAC) of isoflurane in a rat model of
CPB.
METHODS: Male adolescent Sprague-Dawley rats (350-400 gm) were
anesthetized with isoflurane, intubated, ventilated and surgically
prepared for CPB following which they were randomized to either
Sham-operated or CPB groups. The CPB group underwent 90 minutes
of normothermic (37.5 ºC) non-pulsatile CPB (160-180ml/kg/min)
utilizing a membrane oxygenator. The Sham group was cannulated but
did not undergo CPB. Pre- and post-CPB MAC determinations, using a
tail-clamp method (4), were compared within groups using an unpaired
Student‘s T-test. Physiologic values were compared between groups
using a paired Student‘s T-test with a Bonferonni correction to control
for multiple comparisons. A P < 0.05 was considered significant.
RESULTS: Ten rats underwent CPB and 13 rats served as Sham-
operated controls. The rats did not differ with respect to physiologic
values with the exception of PaO2 (445-462 mmHg, CPB vs 284-292
mmHg, Sham; p = 0.005) and pH (7.50-7.52, CPB vs 7.43-7.45, Sham;
p = 0.005). The CPB group had a pre-CPB baseline isoflurane MAC of
1.09 ± 0.11 % vs. 1.09 ± 0.08 % in the Sham group (p = 0.90). Twenty
minutes following CPB, the CPB group exhibited a 10% decrease in
MAC to 0.98 ± 0.14 % (p = 0.0026, compared to baseline; Figure 1).
The MAC in the Sham group was unchanged (p = 0.585, compared to
baseline). Two hours after CPB, the CPB group MAC remained
decreased compared to baseline at 0.99 ± 0.14 % (p = 0.0032).
2003; 96; S-1–S-293
S-36
CIRCULATING PLATELET-LEUKOCYTE ASSOCIATES IN RESULTS: In whole blood samples of Novacor VAD patients a
PATIENTS ON THE NOVACOR AND HEARTMATE significantly higher percentage of platelet-granulocyte associates and
VENTRICULAR ASSIST DEVICE platelet-momocyte associates could be observed compared to the blood
of patients on the HeartMate VAD. P < 0.05, ANOVA
AUTHORS: U. R. Jahn, S. Christiansen, H. Van Aken, H. H. Scheld, DISCUSSION: Since the appearance of platelet-granulocyte and
D. Hammel, B. E. Kehrel platelet-monocyte associates can be attributed to the activation of these
AFFILIATION: Universitaetsklinikum Muenster, Muenster, Germany. different cells, our data indicate, that the degree of platelet and
leukocyte activation might be significantly higher in the Novacor
INTRODUCTION: Platelet-leukocyte adhesion may occur as a system, compared to the HeartMate system.
consequence of both, platelet or leukocyte activation and result in the
formation of platelet-leukocyte associates. They possibly play an
important role in the deposition of activated platelets in a thrombus.
Since hemostasis in patients with implanted left ventricular assist
device (VAD) is still lacking knowledge, we were interested whether
VAD´s differing in material and inner surface may differently activate
the hemostatic system, which may lead to differences in platelet-
leukocyte associates formation.
We therefore studied the ex-vivo platelet-leukocyte associates formation
in patients on left ventricular assist devices with a pulsatile flow, with a
smooth (Novacor) and rough (HeartMate) inner surface. We
investigated the hypothesis, that a rough inner surface may have less
platelet and leukocyte activating properties and may lead to less
extended formation of platelet-leukocyte associates.
METHODS: Platelet-leukocyte associates were identified as platelet-
granulocyte and platelet monocyte associates using flowcytometrical
methods. They were quantified, measuring the percentage of leukocytes
(granulocytes identified by FSC / SSC properties and monocytes
marked with FITC-labeled anti-CD 14) positive for the platelet-specific
marker CD42a.
The study was performed with whole blood samples of 5 patients on the
Novacor VAD and 5 patients on the HeartMate VAD. All patients were
anticoagulated with acetylsalicylic acid, dipyridamole and heparin.
Assist device patients were only included in the study, when the last
surgical intervention was at least 4 weeks ago, when they were on a
normal ward expecting discharge and when they were without any
infection problems.
Cardiothoracic and Vascular –
Cardiothoracic and
Vascular – Clinical
Clinical
S-38 2003; 96; S-1–S-293
S-37
CARDIAC ARRESTS DURING ANESTHESIA FOR patients who were not monitored before arrest with arterial line
NONCARDIAC SURGERY: REVIEW OF 518,249 (P=0.004) and CVP (P<0.001) had better survival. Patients with
ANESTHETICS BETWEEN 1990-2000 IN A TERTIARY hemorrhagic cardiac arrest arrested had the lowest likelihood of
REFERRAL CENTER surviving (P<0.001). From multivariate analysis, after backward
elimination of non-significant variables, the following characteristics
AUTHORS: J. Sprung, G. T. Girgenti, M. Warner, D. R. Schroeder, B. were found to be independent predictors of immediate survival: non-
M. Christopher, D. O. Warner diabetic patients (OR=3.3, P=0.009), patients who were not monitored
AFFILIATION: Mayo Clinic, Rochester, MN. with CVP (OR=2.5, P=0.018), those without intraoperative hypotension
prior to arrest (OR=2.5, P=0.008), patients arresting during standard
OBJECTIVE: To estimate the frequency of cardiac arrest during working hours [Monday to Friday 7:00 to 20:00] (OR=4.1, P=0.007),
anesthesia and characteristics associated with immediate (1-hour) and cause of arrest (OR=1.0 for bleeding, OR=5.8 for cardiac and
survival in patients who experience intraoperative cardiac arrest. OR=13.5 for other, P<0.001).
METHODS: We prospectively ascertained intraoperative cardiac CONCLUSION: Patients with cardiac arrest due to hemorrhage had
arrests that occurred in patients undergoing noncardiac surgery between worse immediate survival compared to those with other causes. Other
January 1, 1990 and December 31, 2000. Survival outcome and predictors of poor outcome (diabetes, use of invasive monitoring,
characteristics potentially associated with survival were abstracted from intraoperative hypotension) may be reflective of patients with
patient records. Logistic regression analysis was performed to assess preexisting co-morbidities. Those who arrested during regular working
characteristics associated with immediate survival. Type of surgery, hours had better immediate outcome than patients that arrested during
ASA classification and urgency of procedure were included as adjuster nights or weekends.
variables in all models. Variables with some evidence (P<0.15) of an
association with immediate survival from the adjusted univariate
analyses were included in a multivariate analysis using backward
elimination of non-significant variables. Two-tailed P-values <0.05
were considered statistically significant.
RESULTS: During the study period intraoperative cardiac arrest
occurred in 233 of 518,294 anesthetics administered (4.3 per 10,000
anesthetics). One hundred and four (46.4%) patients survived at least 1
hour, and seventy-seven (34.5%) survived hospital discharge. Patients
with increased ASA physical status (ASA 1-3 vs ASA 4-5) had lower
likelihood of survival (P<0.001). Survival in patients who had
emergency surgery was lower (30.6%) than in those undergoing elective
surgery (59.2%)(P<0.001). From adjusted univariate analyses (adjusted
for ASA status, and urgency of surgery), the likelihood of survival of at
least one hour was increased with shorter duration of surgery prior to
arrest (P=0.049), in patients not requiring continuous vasopressor
infusions during surgery (P=0.004), in patients who did not have
prolonged intraoperative hypotension before arrest (P<0.001). Also,
S-38
THE RISK OF PERIOPERATIVE CARDIAC 35 vs. 20/105, P < 0.02). The frequency of the other 3 predictors was
COMPLICATIONS IS HIGH IN MAJOR VASCULAR not significantly different: IDDM (11/35 vs. 44/105), history of MI (19/
SURGERY PERFORMED WITHIN A MONTH OF CORONARY 35 vs. 38/105), and serum creatinine > 2 g/dl (9/35 vs. 16/105).
ARTERY BYPASS GRAFT SURGERY (CABG): A CASE- Compared to the control cases, the index cases had significantly greater
rates of perioperative 30-day mortality (7/35 vs. 2/105, P < 0.01) and of
CONTROL STUDY death or nonfatal cardiac complications (12/35 vs. 8/105, P < 0.01).
AUTHORS: K. W. Park DISCUSSION: When matched by demographic variables and by the
AFFILIATION: Beth Israel Deaconess Med Ctr, Boston, MA. intermediate clinical predictors of AHA, patients undergoing major
vascular surgeries within a month of CABG had significantly higher
INTRODUCTION: Prophylactic coronary revascularization (PCR) cardiac complication rates than other patients having similar surgeries.
may be considered before major noncardiac surgery, if the perioperative The benefit of PCR by CABG may not be realized if the subsequent
cardiac risk for the noncardiac surgery is significantly reduced by PCR. vascular surgery is performed within a month of CABG. Whenever
Although retrospective data suggest that prior CABG reduces the possible, major vascular surgery should be delayed at least a month
cardiac risk of subsequent noncardiac surgery, the interval between after CABG.
CABG and noncardiac surgery was not specified (1). We have REFERENCES:
previously showed that patients who had major vascular surgery (1) Circulation 1997; 96:1882-7.
performed within a month of CABG appeared to have very high cardiac (2) Anesth Analg 2002; 94:S63.
complication rates (2). In this study, we extend our previous study to (3) J Am Coll Cardiol 2002; 39:542-53
match the cases with controls and compare the cardiac complication
rates.
METHODS: From our vascular surgical patient database from 1990-
99, we identified 35 patients who had major vascular (16 aortic, 19
peripheral vascular) surgeries within a month of CABG. Three control
patients were then identified per index case by matching age, gender,
race, and type of surgery and by requiring maximum matching of the 5
intermediate clinical predictors of the American Heart Association
(AHA) preoperative cardiac evaluation algorithm (3), which are insulin-
dependent diabetes mellitus (IDDM), history of congestive heart failure
(CHF), history of myocardial infarction (MI), stable angina, and serum
creatinine > 2.0 mg/dl. Rates of cardiac complications (MI, CHF, death)
were compared between the cases and controls by Monte Carlo
randomization test of proportions, with p < 0.05 taken as significant.
RESULTS: Index cases and controls were exactly matched for age (68
± 10), gender distribution (M:F=4:3), and type of surgery by design. Of
the intermediate clinical predictors of AHA, history of CHF was more
common among the index cases (20/35) than controls (33/105) (P <
0.02), while stable angina was less common among the index cases (0/
2003; 96; S-1–S-293 S-40
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A DOSE-RESPONSE STUDY OF PROSTAGLANDIN E1 ON showed a significant decrease at T2 (77.3 ± 9.7 mmHg, p<0.001 vs.
RADICULAR BLOOD FLOW VELOCITY AFTER LUMBAR T1), T3 (70.2 ± 7.9 mmHg, p<0.001 vs. T1, p<0.05 vs. group B), and
DISCECTOMY T4 (71.4 ± 9.6 mmHg, p<0.001 vs. T1, p<0.05 vs. group B), while the
RBFV (14.8 ± 6.0 ml/100g/min at T1) showed a significant increase at
AUTHORS: M. Fukusaki1, M. Miyako2, K. Sumikawa3 T2 (17.7 ± 8.1 ml/100g/min, p<0.05 vs. T1), T3 (18.3 ± 10.8 ml/100g/
AFFILIATION: 1Nagasaki Rosai Hospital, Sasebo, Japan, min, p<0.05 vs. T1), and T4 (20.0 ± 10.2 ml/100g/min, p<0.05 vs. T1).
2
Anesthesia, Sasebo, Japan, 3Anesthesiology, Nagasaki, Japan. There was no significant difference in the RBFV between group B and
group C.
INTRODUCTION: Mechanisms of lumbosacral radiculopathy are CONCLUSION: The results show that low- and moderate- doses of
hypothesized to be ischemic neuritis of the cauda equina or the nerve PGE1 increases radicular blood flow velocity after discectomy. A
root. This study was designed to evaluate the dose-effect relationship of ceiling effect of PGE1 was observed at the dose of 20 mcg or more.
prostaglandin E1 (PGE1) on radicular blood flow velocity (RBFV) after
lumbar discectomy.
METHODS: After institutional approval and informed consent, 48
patients undergoing lumbar discectomy were allocated to one of three
groups. Anesthesia was maintained with N2O-O2-sevoflurane. After
lumbar discectomy, a probe of laser doppler flowmetry was placed
directly on L4 or L5 nerve root to measure RBFV. Group A (N=17)
received intravenous infusion of normal saline for 10 minutes. Group B
(N=18) received intravenous infusion of 20 mcg of PGE1, and group C
(N=13) received intravenous infusion of 50 mcg of PGE1 for 10
minutes, respectively. The RBFV, mean arterial pressure (MAP),
hematocrit (Hct), percutaneus oxygen saturation (SpO2), and end-tidal
carbon dioxide tension (PETCO2) were measured before infusion (T1),
5 minutes after starting injection (T2), 10 minutes after starting infusion
(T3), and 5 minutes after the end of infusion (T4). Statistical
significance (p<0.05) were determined using ANOVA and Scheffe's
test. Data were shown as mean ±SD.
RESULTS: The three groups were similar in Hct, SpO2, and PETCO2.
In group A, MAP and RBFV showed no change throughout the time
course. In group B, the MAP (86.5 ± 9.2 mmHg, at T1) showed a
significant decrease at T2 (78.9 ± 9.1 mmHg, p<0.001 vs. T1), T3 (76.8
± 6.8 mmHg, p<0.001 vs. T1), and T4 (77.7 ± 6.6 mmHg, p<0.001 vs.
T1), while the RBFV (14.5 ± 6.6 ml/100g/min at T1) showed a
significant increase at T2 (17.4 ± 6.8 ml/100g/min, p<0.05 vs. T1), T3
(17.8 ± 8.1 ml/100g/min, p<0.05 vs. T1), and T4 (19.2 ± 8.8 ml/100g/
min, p<0.05 vs. T1). In group C, the MAP (86.2 ± 9.4 mmHg at T1)
S-40
HTK VERSUS UW PRESERVATIVE SOLUTION: HEMO- RESULTS: Are shown in Table 1.
DYNAMIC AND METABOLIC CHANGES DURING ORTHO-
TOPIC LIVER TRANSPLANTATION Table 1: Hemodynamic and metabolic changes during OLT in HTK and UW
1 1 1 1
group
AUTHORS: S. Aggarwal , R. R. Nicolau , R. Planinsic , I. Hilmi , A.
Variables Groups I + 60 III + 30 s III +5 III + 30 III + end
Soaita2, B. Eghtesad1
AFFILIATION: 1UPMC, Presbyterian University Hospital, Pittsburgh, HR HTK 81±15 66±12a,b 80±8b 84±13b 84±14b
PA, 2Graduate School of Public Health, Pittsburgh, PA. beats/m UW 90±16 82±21 95±14 95±13 97±14
MAP HTK 74±11 56±13a 68±11 74±10 71±8
INTRODUCTION:
University of Wisconsin solution (UW) is at present the gold standard mmHg UW 77±9 60±13 67±11 71±11 69±9
for liver preservation. However, UW solution is known to cause early K+ HTK 4±0.5 4.8±1.2a 3.7±0.6 3.7±0.5 3.8±0.6
failure of microcirculation in grafted liver from preservation/
mmol/l UW 3.9±0.7 5.2±1.1a 3.9±0.9 3.8±0.7 3.8±0.6
reperfusion injury. In order to prevent this injury various other
preservation solutions have been studied. Histadine-Tryptophan- BE HTK -2.2±2.5 -3.2±3.4b -2.6±2.9b -2.7±3.3 -4±3.4
Ketoglutarate preservative solution (HTK) has shown to improve the mmol/l UW -4.1±3.3 -5.7±2.9 -5.1±3.3 -4±2.9 -3.4±3.6
microcirculation of the grafted liver [1].
The purpose of this study is to underline the differences between the Lactate HTK 2.4±2.3 6.1±1.9a,b 5.7±1.7a,b 5.6±2.3a,b 5.8±2.9a,b
HTK and UW preservation solutions regarding the hemodynamic and mmol/l UW 3.8±2.6 9±3.7 8.7±3.5 8.3±3.8 8.1±3.6
metabolic effects and the incidence of postreperfusion syndrome (PRS) a
[2] (MAP < 30 % from baseline value within 5 minutes after p < 0.05 from baseline, b p < 0.05 between the groups
reperfusion), during orthotopic liver transplantation (OLT). Incidence of PRS was 40 % in HTK group and 25 % in UW group.
METHODS: After IRB approval, 40 adult patients (55 ± 10 years), 23 DISCUSSION: 1) In the HTK group the incidence of PRS is more
males and 17 females undergoing first OLT were prospectively studied. frequent, however the recovery from hemodynamic instability is faster.
They were divided into two groups of 20 patients each depending on 2) In HTK group, a lower serum lactate level indicates a better graft
preservation solutions used HTK versus UW. Before reperfusion function.
grafted liver was flushed via the portal vein with cold lactated Ringer's REFERENCES:
solution in UW group while liver in HTK group was not flushed. 1. Transpl Int, 7, 177-181,1994.
Measured hemodynamic and metabolic variables included: heart rate 2. Journal of Critical Care, 8 (3), 154-160, 1993.
(HR), mean arterial pressure (MAP), central venous pressure (CVP),
pulmonary artery pressure (PAP), cardiac output (CO), systemic
vascular resistance (SVR) and serum potassium (K+), ionized calcium
(Ca++), base deficit (BE), serum lactate. Variables were measured at I
+60 (60 minutes after skin incision), III +30 s (30 seconds after
reperfusion), III +5 (5 minutes after reperfusion), III +30 (30 minutes
after reperfusion) and III +end (final sample). Data is presented as mean
value ± standard deviation.
S-42 2003; 96; S-1–S-293
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PREOPERATIVE BETA-BLOCKADE TO A DESIRED HEART Vasc-BB vs. Vasc-noBB was significant (p<0.001, Fischer exact test).
RATE DOES NOT NECESSARILY ACHIEVE DESIRED Surprisingly, the peak intraoperative HR response was not significantly
INTRAOPERATIVE HEART RATE blunted in Vasc-BB vs. Vasc-noBB (82.4/min ±13.0 vs. 85.2/min±15.8)
(Table).
AUTHORS: S. Akhtar1, M. Amin2, H. Tantawy2, J. Whipple2, P. G. CONCLUSION: Our study suggests that a more aggressive approach
Barash2, D. G. Silverman2 is required to increase use of preoperative b-blocker therapy in suitable
AFFILIATION: 1VA Connecticut Healthcare System, West Haven, patients. Even though the average HR in patient on BB was similar to
CT, 2Department of Anesthesiology, Yale University School of one achieved by Poldermans et al, intraoperative increase in HR was
still significant. Anesthesiologist need to be vigilant, as routine
Medicine, New Haven, CT. preoperative BB use does not prevent intraoperative increase in HR and
INTRODUCTION: b-blockers (BB) decrease postoperative cardiac supplemental prophylactic BB may be required to control intraoperative
morbidity and mortality1. Of the proposed mechanisms associated with HR effectively.
their beneficial effects, a decrease in oxygen demand secondary to REFERENCES:
decreased chronotropy is hypothesized to play a major role. The 90% 1. NEJM 341(24);1789, 1999
decrease in cardiac events reported by Poldermans et al1 was seen in a 2. JACC 39(3), 2002
protocol where BB were titrated preoperatively to a heart rate (HR) =60 3. JAMA 287(11);1445, 2002
bpm (or to a max. of 10 mg bisoprolol, mean HR 66/min) and PEAK PEAK PEAK
maintenance of stringent perioperative HR control. Recent ACC/AHA Patients Age (SD)
PAT HR PAT SBP PAT-DBP
Intraoperative Intraoperative Intraoperative
(SD) (SD) (SD)
Guidelines recommend titrating preoperative BB to maintain resting HR/min (SD) SBP (SD) DBP (SD)
HR between 50-60 bpm2. Recent recommendations by Auerbach and Vasc-BB 69.8 (9.6) 65.6 (10.8) 141.5 (23.6) 73.8 (11.2) 82.4 (13.1) 168.9 (20.1) 86.4 (14.3)
Vasc-no BB 70.1 (14.9) 71.5 (15.5) 139.2 (36.9) 71.5 (19.6) 85.8 (15.7) 167.2 (29.8) 85.2 (15.8)
Goldman et al3 further define patients who may benefit from
perioperative beta-blocker use. This study was conducted to determine:
(1) the prevalence of BB use in high risk populations (as defined by
Auerbach et al), and (2) to evaluate their baseline HR and peak
intraoperative HR response as a measure of adequacy of perioperative
b-blockade.
METHODS: A retrospective review of the pre-anesthetic assessment
record was conducted on 188 consecutive patients who were scheduled
to undergo major vascular surgery (CEA, supra and infrainguinal
bypass, thoracic and aortic abdominal aneurysm) between Jan 2001 to
March 2002 at Yale-New Haven Hospital. Demographic data,
medications, pertinent review of systems and resting HR and BP, while
in the Pre-Admission Center, were obtained from the electronic records.
Peak intraoperative HR and BP were obtained from chart review.
Patients were grouped as: i) vascular patients on BB (Vasc-BB), ii)
vascular patients not on BB (Vasc-no BB). Data are presented as mean
±SD and analyzed by ANOVA and Fischer exact test. P 60 bpm for
S-42
TRACHEAL INTUBATION IN SIMULATED GRADE III performs less well and introduces the more important risk of failed
DIFFICULT LARYNGOSCOPY: COMPARISON OF SINGLE- intubation. It is not possible to blind a study such as this, and it would
USE PLASTIC AND MULTIPLE-USE GUM ELASTIC BOUGIE be very important for others to repeat our findings, to minimise the risk
of bias. A rational approach would be to suggest that: where a bougie is
AUTHORS: J. J. Pandit, A. G. Marfin, K. Hames, M. T. Popat to be used routinely in all patients the single-use bougie should be used;
AFFILIATION: Nuffield Department of Anaesthetics, Oxford, United in a lifesaving situation in occasional patients, the older, gum elastic
Kingdom. type should be used. Alternatively, in the latter instance, a fibreoptic
scope may also be used (7).
INTRODUCTION: The gum elastic bougie is the most commonly REFERENCES:
used aid to facilitate intubation during grade III laryngoscopy (1). 1. Anaesthesia 1992; 47: 878-81.
Traditionally in the United Kingdom, the multiple-use gum elastic 2. Anaesthesia 1995: 283-5.
bougie has been used (1), which is washed (but not sterilised) between 3. Anaesthesia 2001: 56: 1121.
uses. With increasing concern regarding multiple-use devices and cross- 4. Anaesthesia 2002: 57: 727.
infection (2), a new single-use bougie has been introduced. Anecdotally, 5. Can J Anesth 2002; 49: 448-52.
it appears that any bougie which lacks flexibility and curvature is more 6. Anaesthesia 2000; 55: 274-9.
difficult to use (3,4). The purpose of this study was to compare success 7. Anaesthesia 2002; 57: 123-7.
rates for tracheal intubation in simulated Cormack and Lehane Grade III
laryngoscopy (3).
METHODS: We studied 32 ASA I and II adult patients (day-case
dental procedures). Simulation of grade IIIa laryngeal view (epiglottis
only just obscuring the view of the arytenoids) was achieved by
lowering the Macintosh laryngoscope blade (5,6). One operator
maintained the laryngoscope in position while another attempted
intubation. Patients were randomised to either the new single-use plastic
bougie (New) or multiple-use gum elastic bougie (Old). If the
intubation failed with the first device (one attempt only), the alternative
study device was used. Success rates and intubation times were
recorded.
RESULTS: The Old bougie was successful in 15/16 cases; the New
bougie in only 9/16 cases (2 test with Yates’ correction, P<0.041). Of the
7 cases which failed with the New bougie, the Old was successful in 5.
The New was successful in the single case in which the Old failed. Total
intubating times were under 85 sec in all cases, and there were no
significant differences between the groups.
CONCLUSIONS: The difference in success rates between the Old and
New bougies is striking. Although minimising the risk of cross-
infection is important, it is of concern that the newly-introduced device
2003; 96; S-1–S-293 S-44
S-43
TRACHEAL INTUBATION IN SIMULATED GRADE III P<0.04). In all successful intubations using either technique, the total
DIFFICULT LARYNGOSCOPY: COMPARISON OF THE intubating times were within 120 sec and there were no significant
FIBREOPTIC SCOPE AND PLASTIC BOUGIE differences between the times using the two devices.
CONCLUSIONS: In simulated grade IIIa laryngoscopy, the fibreoptic
AUTHORS: J. J. Pandit1, K. Hames1, A. G. Marfin1, M. Popat1, S. M. scope is very much more successful than the bougie as a device for
Yentis2 intubation. The same dramatic degree of success could not be
AFFILIATION: 1Nuffield Department of Anaesthetics, Oxford, demonstrated in a grade IIIb laryngoscopy, although the fibreoptic
United Kingdom, 2Magill Department of Anaesthesia, London, United scope was still statistically better than the bougie. The results have at
least three important clinical implications: (a) previously suggested sub-
Kingdom. divisions of the grade III view may be clinically important (4); (b) the
INTRODUCTION: The bougie is the most commonly used aid to bougie may not be the device of choice in an unexpected grade III
facilitate intubation during grade III laryngoscopy (1). The technique is laryngoscopy; (c) a patient with a known, previously recorded grade III
blind and multiple attempts may cause airway trauma. Flexible laryngoscopy might reasonably be considered sufficiently "difficult’ for
fibreoptic endoscopy offers a continuous view and may minimise an awake intubation technique.
trauma (2). We compared the fibreoptic scope and single use bougie for REFERENCES:
orotracheal intubation in two different simulated grade III 1. Anaesthesia 1992; 47: 878-81.
laryngoscopic views. 2.Anaesthesia 2002; 57: 123-7.
METHODS: We studied 64 ASA I and II adult patients (day-case 3.Can J Anesth 2002; 49: 448-52.
dental procedures). Simulation of laryngeal view was achieved by 4. Anaesthesia 2000; 55: 274-9.
lowering the Macintosh laryngoscope blade (3). In 32 patients, a grade
IIIa view was simulated (epiglottis only just obscuring the view of the
arytenoids). In 32 patients a grade IIIb view was simulated (epiglottis
touching the posterior pharyngeal wall). One operator maintained the
laryngoscope in position while another attempted intubation. Patients
were randomised to either fibreoptic scope or bougie. If the intubation
failed with the first device (one attempt only), the alternative study
device was used. Success rates and intubation times were recorded.
RESULTS: (A) Grade IIIa view: All 16 (100%) of the fibreoptic-
guided intubations were successful compared with 8 (50%) where a
bougie was used (2 test, P<0.02). The fibreoptic scope was successful in
all 8 patients in whom the bougie had failed as the primary method. (B)
Grade IIIb view: The fibreoptic scope was successful in 8 (50%) cases,
compared with 1 (6%) case using the bougie (2 test, P<0.02). Where the
bougie had failed as the original method, the fibreoptic scope was
successful in 10 (67%) cases; where the fibreoptic scope was
unsuccessful initially, the bougie succeeded in only 1 (13%) case (2 test,
S-44
POSITIVE PRESSURE VENTILATION AND ISOFLURANE DISCUSSION: PPV increases VDPHYS; isoflurane significantly
INCREASE PHYSIOLOGIC DEADSPACE VOLUME (VDPHYS) potentiates this increase. The significant increase in VDANA following
IN PATIENTS RECEIVING GENERAL ANESTHESIA isoflurane may be related to its bronchodilating effects. Compromised
blood gas exchange, as reflected by a decreased PaO2/FIO2 ratio, most
AUTHORS: C. Praetel, M. J. Banner, T. G. Monk, A. Gabrielli likely results from increased VDPHYS. During controlled mechanical
AFFILIATION: University of Florida College of Medicine, ventilation with a paralyzed patient, as during general anesthesia, a
Gainesville, FL. disproportionate amount of the tidal volume is directed to the anterior
nondependent lung regions predisposing to areas of increased
INTRODUCTION: Increased VDPHYS, including alveolar (VDALV) ventilation-to-perfusion matching, i. e., increased VDPHYS.2 A
and anatomic deadspace volume (VDANA), predisposes to impaired mechanism for how isoflurane increases VDPHYS is unclear, it may be
arterial blood gas exchange. For patients receiving general anesthesia, the result of its vasodilating effects and possible redistribution of
the interaction effects of positive pressure ventilation (PPV) and inhaled pulmonary blood flow.
isoflurane (Iso) on VDPHYS is not clear. We hypothesized both factors REFERENCES:
promote increases in VDPHYS and for different physiologic reasons. 1. Arnold et al: Crit Care Med 1996; 24: 96
METHODS: IRB consent was obtained on 18 adults scheduled to 2. Froese et al: Anesthesiology 1974; 41: 242
receive general anesthesia (age 50 ± 14 years, weight 79 ± 16 kg, 7
males, 11 females). A combined pressure/flow/carbon dioxide (CO2)
sensor directed to a monitor (Novametrix-Respironics) was used to
measure the various deasdspace volumes by the single breath CO2
elimination method.1 The PaO2 / FIO2 ratio was calculated.
Measurements were obtained preoperatively during spontaneous
ventilation (SV) (sensor attached to mouthpiece) and intraoperatively
(sensor attached to endotracheal tube), i. e., after induction during PPV
and intravenous anesthesia and then 30 min later breathing 1 MAC Iso
while maintaining minute ventilation, mean airway pressure, and mean
arterial blood pressure constant. Data were analyzed using a repeated
measures ANOVA; alpha was set at .05 for statistical significance.
RESULTS:
Condition VDPHYS VDALV VDANA PaO2/FIO2
Pre-op SV 147 ± 51 42 ± 31 105 ± 28 395 ± 8
PPV 242 ± 67* 131 ± 46* 112 ± 34 383 ± 74
Iso plus PPV 289 ± 56+ 163 ± 40+ 126 ± 27+ 337 ± 86+
p < .05, Pre-op SV vs PPV(*), PPV vs Iso plus PPV (+)
S-46 2003; 96; S-1–S-293
S-45
POSTOPERATIVE HYPERTHERMIA FOLLOWING OFF-PUMP temperature and AUC>38oC were higher in the on-pump patients
VS. ON-PUMP CORONARY ARTERY BYPASS SURGERY (38.5+0.4oC, on-pump vs. 37.9+0.5oC, off-pump, p=0.002; and 1.6+1.7oC.h,
AUTHORS: S. Bar-Yosef1, J. P. Mathew1, A. C. Anderson1, M. F. on pump vs. 0.4+1.2oC.h, off-pump, p=0.02). Of the on-pump patients, 89%
Newman1, K. P. Landolfo2, H. P. Grocott1 had temperature elevations above 38oC, vs. 44% of the off-pump patients (p =
0.04).
AFFILIATION: 1Department of Anesthesiology, Duke University
Medical Center, Durham, NC, 2Department of Surgery, Duke University
Medical Center, Durham, NC.
INTRODUCTION: Fever is common in the first 24 hours following
coronary artery bypass graft surgery (CABG) utilizing cardiopulmonary
bypass (CPB) [1]. The inflammatory response to CPB is often implicated in
the etiology of this fever [2], which has recently been associated with an
increase in post-cardiac surgery neurocognitive dysfunction [3]. The
temperature pattern after off-pump cardiac surgery (OPCAB), where CPB is
avoided, has not yet been described. The purpose of this study was to describe
the post-operative temperature pattern following OPCAB and to compare it
to that following on-pump cardiac surgery.
METHODS: Following IRB approval, patients undergoing either off-pump
or on-pump CABG surgery were studied. The off-pump group was enrolled
in an unrelated OPCAB study in which normothermia (nasopharyngeal
temperature >36oC) was maintained throughout the operation. The on-pump
group was consented for the same OPCAB trial but subsequently converted
to on-pump cardiac surgery using hypothermic (32-34oC) CPB. All patients DISCUSSION: We have previously reported hyperthermia in the first 24
were managed identically after admission to the intensive care unit (ICU), hours following conventional on-pump CABG [1]. In the current study, we
including forced-air warming for those with a temperature <36oC and found that off-pump surgery was accompanied by a lesser degree of early
acetaminophen for temperatures > 38oC. Temperature measurements in the postoperative fever, although significant hyperthermia still occurred in both
ICU were recorded hourly from the pulmonary artery catheter thermistor groups. This hyperthermia in OPCAB surgery may be related to a lesser, but
during the first 24 post-operative hours. To quantify temperature changes, the still evident, inflammatory response [4]. However, the different fever patterns
may also be related to differences in the extent of operative trauma, drug
areas under the temperature-time curve (AUC) for temperatures >38oC and therapy, blood transfusion or pulmonary atelectasis [5].
<36oC were calculated. Between group comparisons were made by Student’s REFERENCES:
t-test or 2 test with P<0.05 considered significant. 1. Anesthesiology: 2000. 93: A166.
RESULTS: Forty-one patients (age 61+10 years, 63% males) were enrolled, 2. Anesthesiology: 2002. 97(1): 215-52.
32 in the off-pump group and 9 in the on-pump group. No differences were 3. Stroke: 2002. 33(2): 537-41.
found between the off-pump and on-pump patients regarding ICU admission 4. Ann Thorac Surg: 2001. 72(6): S2260-5; discussion S2265-6, S2267-70.
temperature, minimal temperature or AUC<36oC. However, peak body 5. Chest: 2000. 117(3): 855-69.
S-46
MEDIUM-TERM OUTCOME FOLLOWING CORONARY symptomatology (shortness of breath indices at 6- and 12-months [New
REVASCULARIZATION: CPB VERSUS OP-CAB York Heart Association Classification 0.43 ± 1.17 v 1.00 ± 1.24; p =
0.06 and 0.38 ± 1.24 v 0.74 ± 0.96; p = 0.13]; postoperative angina
AUTHORS: A. Grattan1, A. Smith1, T. Kelly2, A. Shaw2, D. Royston1, score at 12-months [Canadian Cardiovascular Society Classification 0 v
B. J. Riedel2 0.33 ± 0.80; p = 0.05]) and quality of life at 6-months (Duke Activity
AFFILIATION: 1Royal Brompton & Harefield NHS Trust, London, Status Index 20.8 ± 5.6 v 19.0 ± 6.8; p = 0.13). No differences were
United Kingdom, 2University of Texas M. D. Anderson Cancer Center, observed in the incidence of cardiology-based intervention or death (3 v
Houston, TX. 4 patients and 2 v 1 patients, respectively) between groups.
DISCUSSION: The observed reduction in incidence of IMI associated
INTRODUCTION: Ischemic myocardial injury (IMI) is abundant (up with OP-CAB may contribute to the lower requirement for increased
to 30%) following cardiac surgery,(1) with increasing evidence of cardiovascular medication and observed trend in improved symptoms at
associated adverse medium-term outcome.(2) Minimizing IMI is medium term follow-up. Larger prospective, randomized studies are
therefore an important goal. Studies have shown that off-pump coronary required to determine the impact of OP-CAB on medium- and long-
artery bypass surgery (OP-CAB) reduces IMI.(3) Similarly, we reported term benefit in the cardiac surgical population.
less IMI [troponin-I >15 g.L-1: 19.0% vs. 91.3%; p = 0.0001; troponin- REFERENCES:
I >30 g.L-1: 9.5% vs. 52.2%; p = 0.003] following OP-CAB compared 1. Anesthesiology 1989;71:818-26.
to surgery using conventional cardiopulmonary bypass (CPB).(4) Here 2. J Am Coll Cardiol 2001;38:1070-7.
we report on the medium-term follow-up of this cohort of patients. 3. Eur J Med Res 2000;5:222-8.
METHODS: Forty-four patients were followed-up at 6- and 12-months 4. J Cardiothorac Vasc Anesth 2002;16:413-20.
following elective multivessel coronary surgery using either OP-CAB
(n = 23) or conventional CPB (n = 21) techniques. Medium-term
outcome variables that were assessed by postal questionnaire and
patient medical record review included indices of patient
symptomatology, quality of life and the occurrence of cardiovascular
events and death following hospital discharge. Data are presented as
mean ± SD and as a percentage of the study group for continuous and
categorical variables, respectively. Univariate analyses used Fisher’s
exact test for categorical variables and the Mann-Whitney U test for
nonparametric variables. A p-value of <0.05 and <0.2 were regarded as
statistically significant and as a trend towards difference between the
two groups, respectively.
RESULTS: Preoperative and intraoperative data were similar between
groups.(4) At medium-term follow-up significantly fewer patients
required increased cardiovascular medication (5.6% v 47.1%; p =
0.007) in the OP-CAB group at 6-month follow-up. This advantage was
no longer evident at 12-month follow-up (23.5% v 28.6%; p = 1.0). The
OP-CAB group also demonstrated trends toward improved variables of
2003; 96; S-1–S-293 S-48
S-47
ULTRA-FAST-TRACK ANESTHESIA IN OFF-PUMP scores postoperatively were low in both groups, significantly lower in the
CARDIAC SURGERY: POSTOPERATIVE EPIDURAL TEA group than in the PCA group 6 - 48 h after surgery (Figure).
ANALGESIA VERSUS PCA MORPHINE
AUTHORS: J. D. Fortier, J. Choiniere, F. Basile, I. Prieto, T.
Hemmerling
AFFILIATION: University of Montreal, Montreal, PQ, Canada.
INTRODUCTION: This study investigated how operating room
extubation can be achieved using either epidural based anesthesia or a
modified balanced anesthesia during off-pump cardiac surgery (CABG).
METHODS: The study was designed as a prospective audit of 53 patients
undergoing off-pump CABG. The goal was to maintain the patient‘s core
temperature during surgery of more than 35.5 degrees C by active
temperature control. Anesthesia was either an anesthesia using sevoflurane
titrated by BIS and a continuous thoracic epidural analgesia (N=33, TEA
group) or a modified balanced anesthesia using sevoflurane/fentanyl boli
(<15 microg/kg total, PCA group) in patients on either low molecular
heparine or intravenous heparine (N=20). If extubation could not be
achieved within 30 min after surgery (or core temperature was below 35.5),
the patient was transferred to the ICU intubated and ventilated.
Postoperative analgesia during the first 48 hours was achieved by either
thoracic epidural analgesia (TEA, bupivacaine 0.125 %) or patient Six patients in the PCA group developed a confusional state
controlled application of morphine (PCA, 1 mg, lockout period: 6 min). necessitating abandoning the PCA. Six patients experienced paresthesia
Anthropometric data, success of extubation, postoperative hemodynamic in both arms which stopped after diminishing the infusion rate of TEA
and respiratory parameters and pain scores are presented as means (SD) and without changing the quality of analgesia.
compared between the two groups using t-test (P<0.05). DISCUSSION: Our results indicate that Ultra Fast Track anaesthesia
RESULTS: Fifty-three patients (10 women, 43 men) of mean age of 60 yrs can be achieved with either TEA based or a conventional low dose
(12), weight of 81 (15) kg and an ejection fraction of 55 (10) % undergoing fentanyl balanced anesthesia using sevoflurane. Maintenance of core
off-pump CABG of 3 grafts (0.8) during surgery of 120 (28) min were body temperature is the most important task to allow operating room
included. The anthropometric data and surgery-related parameters extubation. PCA morphine is an alternative for patients where TEA is
(concomitant disease, ejection fraction, number of grafts, ischemic time) contraindicated or impossible. Lower postoperative pain scores and
were not different between the two groups. Three patients were not better side effect profile, however, favor TEA as a technique when there
extubated due to low core temperature. Time to extubation, first PO2 and are no contraindications for its use.
PCO2 (FiO2 = 100 %) after extubation were 15 (4) and 14 (5) min, 158
(60) mmHg and 142 (44) mmHg, 47 (10) mmHg and 49 (8) mmHg in the
TEA and PCA groups, respectively and not significantly different. Pain
S-48
OPERATING ROOM EXTUBATION IN SIMPLE AND either TEA based or a conventional balanced anesthesia using low dose
COMPLICATED AORTIC VALVE SURGERY: A FIRST fentanyl and sevoflurane.
EXPERIENCE TABLE N=10
Age (y) 61 (18)
AUTHORS: J. D. Fortier, J. Choiniere, F. Basile, I. Prieto, T. M. Weight (kg) 71 (11)
Hemmerling Sex (m/f) 5/5
AFFILIATION: University of Montreal, Montreal, PQ, Canada. Valve (mech/bio) 4/6
Stenosis (Regurgitation) 7/3
INTRODUCTION: This study presents a first series of 10 patients Surgery (min) 123 (28)
where operating room extubation was achieved in simple (Aortic valve Ejection fraction (%) 60 (8)
replacement only) and complicated (additional replacement of the Systolic pressure immediately after surgery (mmHg) 123 (36)
ascending aorta or CABG) aortic valve surgery using either TEA based Diastolic pressure immediately after surgery (mmHg) 59 (18)
anesthesia or a modified balanced anesthesia. Duration of TEA or PCA (d) 2.6 (0.7)
METHODS: The study was designed as a prospective audit of 10
patients undergoing aortic valve surgery. The goal was to immediately
extubate the patients. Anesthesia was either an anesthesia using
sevoflurane titrated by BIS and a continuous thoracic epidural analgesia
(N=8, installed at arrival in the OR) or a modified balanced anesthesia
using sevoflurane/fentanyl boli (<10 microg/kg total, propofol/
remifentanil during bypass period, N=2). Postoperative analgesia
during the first 48 hours was achieved by either thoracic epidural
analgesia (TEA, bupivacaine 0.125 %) or patient controlled application
of morphine (PCA, 1 mg, lockout period: 6 min). Anthropometric data,
success of extubation, postoperative hemodynamic and respiratory
parameters and pain scores are presented as means (SD).
RESULTS: All ten patients undergoing simple aortic valve surgery
(N=6), aortic valve surgery and CABG (N=2) and Bentall procedure
(N=2) could be extubated. Table 1 present anthropometric data and
surgery-related parameters. Mean time to extubation was 14 (6) min,
first PO2 and PCO2 (FiO2 = 100 %) after extubation were 144 (48) and
47 (2) mmHg, respectively. Pain scores postoperatively were low with
2.3 (2), 1.9 (1.8), 1.2 (0.8), 1 (0.9) immediately, 6 h, 24 h and 48 h after
surgery, respectively. There were no complications. Two of the four
patients where a mechanic valve was implanted had an epidural catheter
inserted which was removed 52 h after surgery with INR lower than 1.4.
DISCUSSION: Our results indicate that Ultra Fast Track anaesthesia
can be achieved in simple and complicated aortic valve surgery with
S-50 2003; 96; S-1–S-293
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EARLY EXTUBATION IN 100 CONSECUTIVE PATIENTS (A: 53+/-13, B: 57+/-15, NE: 66+/-22%). Age, surgery and CPB times
AFTER CARDIAC SURGERY WITH CARDIOPULMONARY were significant factors for early or late extubation.
BYPASS CONCLUSION: In this study, failure of early extubation was related to
the patient status (age, surgery, haemodynamic state) and not to the
AUTHORS: C. J. ISETTA1, L. M. Giurgiuman1, B. MALZAC2 anaesthesia technique. Early extubation was achieved in 62% of the
AFFILIATION: 1Hôpital Pasteur, Nice, France, 2Hôpital Pasteur, Nice, patients without complications.
Finland.
Group A Group B P (A/B) NE
INTRODUCTION: Early extubation before the 6th postoperative hour N* 62 29 <0.05 9
(POH) after cardiac surgery with CP is a technique which may produce
lower medical costs. Prospectively the practice of early extubation has Age* (y) 33 16 <0.05 4
been evaluated in 100 consecutive patients, including emergencies Weight (kg) 63+/-14 70+/-11 >0.05 74+/-7
undergoing cardiac surgery with cardiopulmonary bypass (CPB) A X-clamp (min) 71+/-29 78+/-25 >0.05 80+/-38
METHOD: After approval by the local ethic comittee and informed
written consent, data of the extubated patients up to (group A) and after CPB time* (min) 104+/-40 129+/-40 <0.05 141+/-73
(group B) the 6th POH werecompared. Anasthesia was inducted and Surgery t* (h) 4.5+/-0.9 5.0+/-1.0 <0.05 5.4+/-1.3
mainained with thiopental (one single dose of 2 mg kg -1), midazolam S (mcg kg-1 h-1) 0.92+/-0.46 0.93+/-0.48 >0.05 0.88+/-0.29
(M), sufentanil (S) and pancuronium (P). Enflurane was used to treat
episodes of arterial hypertension. The extubation criteria were M (mcg kg-1 h-1 0.04+/-0.02 0.04+/-0.01 >0.05 0.03+/-0.02
haemodynamic stability, no obvious neurological injury, arterial P (mcg kg-1h-1 0.03+/-0.01 0.03+/-0.1 >0.05 0.03+/-0.01
saturation>92% and PaCO2<86 kPa during spontaneous ventilation on
a tube with 3 litres of oxygen min-1. Statistical analysis was performed
with analysis of variance, chi-squared or Pearson test as appropriate at
P<0,05 (*). All results are expressed as mean +/- SD (table).
RESULTS: Of 100 patients, 62 were extubated up to the 6th POH
(ventilation time: 4.5+/-1.1 h), 29 were extubated after the 6th POH
(12.3+/-10.5 h). The operation for 9 patients was an emergency (4
patients died, 2 were extubated before the 6th POH and 3 after). One
patient (group B) was re-intubated on the 9th POH (hypercapnia). One
patient remained intubated (haemostatic surgery on the 7th POH). After
the 2nd postoperative day, 4 patients were re-intubated because of a low
cardias output (myocardial infarction) in one and infection
pneumopathies in three, one in group A. Nine patients were never
extubated (NE) and 12 patients died (3 in group B after re-intubation).
In group B, 8 patients of 29 (28%) needed high dose inotropes, in
contrast to none in group A. The preoperative left ventricle ejection
fraction was not predictive of the length of the postoperative ventilation
S-50
INTRAOPERATIVE 15-F2T-ISOPROSTANE (8-ISO-PGF2 ) IS A isoprostane increased significantly during ischemia in both groups (P <
PREDICTOR OF POST-OPERATIVE CARDIAC FUNCTION 0.01 vs baseline). 15-F2t-isoprostane in group I decayed exponentially
FOLLOWING WARM HEART SURGERY during reperfusion and returned to baseline at Rep-10’ (P > 0.05 vs
baseline). To the contrary, 15-F2t-isoprostane in group II remained
AUTHORS: D. M. Ansley, Z. Xia, B. S. Dhaliwal significantly higher than baseline at Rep-10’ and Rep-30’ (P < 0.001, vs
AFFILIATION: Centre for Anesthesia & Analgesia, Depts. of baseline) until Rep-120’ (P >0.05 vs baseline). The percentage change
Anesthesia and Pharmacology & Therapeutics, University of British in F2t-isoprostane from Rep-10’ to Rep-30’ was highly inversely
Columbia, Vancouver, BC, Canada. correlated with postoperative cardiac index (CI) (n =13; r = -0.8361,
95%CI: -0.9496 to -0.5286, P = 0.0004).
INTRODUCTION: Despite recent advances in surgical and anesthetic CONCLUSION: The oxidative stress during myocardial reperfusion
technique, postoperative low cardiac output syndrome still occurs in 10 has significant impact on postoperative myocardial functional recovery.
to 20% patients (1,2). This reflects inadequate cardiac protection, which The percentage change in plasma 15-F2t-isoprostane during the early
may attributable to oxygen free radical mediated ischemia-reperfusion phase of reperfusion may serve as a predictor of postoperative cardiac
injury. We postulated that intraoperative plasma 15-F2t-isoprostane, a function following warm heart surgery.
specific and bio-active (3) marker of oxidant stress, is a determinant of REFERENCE:
postoperative cardiac function. 1.Circulation 1991;84(5 Suppl):III380-8.
METHODS: Following ethics committee approval, thirteen patients 2.Circulation 1995;92(9 Suppl):II341-6.
scheduled for coronary artery bypass grafting surgery (CABG) using 3. J Cardiovasc Pharmacol 1997;29(6):789-94.
CPB were enrolled. Patients were anesthetized with fentanyl 10-15 ug/
kg and isoflurane 0.5-2% end tidal. Normothermic CPB and
intermittent blood:crystalloid cardioplegia were utilized during surgery.
Central venous blood samples were collected at baseline, 30 min global
myocardial ischemia, 10 (Rep-10’), 30 (Rep-30’), 120 min (Rep-120’)
and 12 hours (Rep-12 hours) after aortic declamping (reperfusion).
Plasma free 15-F2t-isoprostane was measured by enzyme immunoassay.
Inotropic support was defined as any use of dopamine > 4 g/kg/min,
epinephrine > 0.04 g/kg/min, or milrinone 0.25 - 1.0 g/kg/min, alone
or in combination, required for > 30 min during the first 6 hours
postoperatively to achieve systolic BP > 90 mmHg and CI > 2.2 L/min/
m2. Patient data were analyzed as a whole and by group according to
inotrope requirements for hemodynamic stabilization : Group I (n=7; no
inotropes); Group II (n=6; two or more inotropes). Data were expressed
as mean ± SEM.
RESULTS: There was no difference in age (age 69.0 ± 3.4 vs 60.3 ±
2.3 yr), gender (4/2 vs 5/2 male/female), preoperative LVEF (55.7± 6.3
vs 58.2 ± 3.0%), duration of ACC (108.5 ± 16.1 vs 112.7 ± 31.3 min), or
CPB (150.8 ± 25.0 vs 141.0 ± 36.6 min) between groups. Plasma 15-F2t-
2003; 96; S-1–S-293 S-52
S-51
ANTIOXIDANT THERAPY DECREASES PLASMA performed using ANOVA. Data was expressed as mean± SEM.
ENDOTHELIN-1 AND THROMBOXANE B2 AFTER RESULTS: : There was no difference in age (8.6± 1.3 vs 8.1± 1.3 yr),
CARDIOPULMONARY BYPASS IN PATIENTS WITH body weight (22.9± 2.4 vs 21.9± 2.2 kg), aortic crossclamp (40.7± 3.7
CONGENITAL HEART DISEASE vs 45.5± 3.9 min) and CPB times (75.7± 4.2 vs 77.6± 4.6 min) between
groups. Baseline (T0) values of MDA (3.07± 0.39 vs 2.85± 0.37 nmol/
AUTHORS: Z. Xia1, J. Gu2, D. M. Ansley1, F. Xia2, J. Yu2 mL), CK-MB (21.7± 1.1 vs 22.3± 2.9 U/L), 6-Keto-PGF1 , TXB2, 6-
AFFILIATION: 1Centre for Anesthesia & Analgesia, Depts. of Keto-PGF1 /TXB2 ratio and ET-1 did not differ between groups. MDA
Anesthesia and Pharmacology & Therapeutics, University of British increased significantly at T1 in group A and remained significantly
Columbia, Vancouver, BC, Canada, 2Department of Anesthesiology, higher than group B thereafter (P<0.05). MDA in group B did not
Affiliated Renmin Hospital, Wuhan University, Wuhan, China. significantly increase over time. At T5, plasma CK-MB, TXB2 and ET-
1 in group B were lower, and 6-Keto-PGF1 /TXB2 ratio was higher than
INTRODUCTION: The endothelium-derived vasoconstrictor group A (P<0.05), MDA correlated significantly with CK-MB
endothelin-1 (ET-1) is increased after cardiopulmonary bypass (CPB) (r=0.7074, P=0.0005), and ET-1 (r=0.5070, P=0.0225). At T6, ET-1 was
surgery, which affects postoperative recovery (1). Oxidative stress has negatively correlated with 6-Keto-PGF1 /TXB2 ratio (r= -0.6015,
been reported to increase ET-1 synthesis in human coronary artery
smooth muscle cells (2). The purpose of this study was to 1) determine P=0.005). Six patients in group A (6/10) and one in group B (1/10)
if antioxidant therapy with salvia miltiorrhiza (SM) injection, an herb needed postoperative inotropic support (P<0.05, Chi square test).
extract containing phenolic compounds with potent antioxidant CONCLUSION: Antioxidant therapy with SM reduces postoperative
properties (3), could prevent the postoperative increase of ET-1; 2) myocardial damage and attenuates vascular endothelial dysfunction as
determine the relationship between ET-1 and the endothelium-derived expressed by ET-1 levels, resulting in reduced need for hemodynamic
vasodilator prostacyclin (PGI2) and vasoconstrictor thromboxane A2 support following surgery for CHD.
(TXA2) postoperatively. REFERENCES:
METHODS: Following ethics committee approval, 20 children with 1.J Cardiothorac Vasc Anesth 2000;14(5):540-5.
congenital heart defects (CHD) and moderate pulmonary hypertension 2.J Cardiovasc Pharmacol 2001;38(1):49-57.
(mean pulmonary pressure/mean systemic pressure 0.3 to 0.4) were 3.Biochem Pharmacol 1992;43(2):147-52.
enrolled. Prior to cardiac surgery, patients were randomly assigned to
group A (placebo control; n=10) and B (200 mg/kg SM intravenously
after anesthesia induction and at the time of rewarming; n =10). Central
venous blood samples were taken: before operation (T0), 10 (T1) and 30
min (T2) after starting CPB, 10 (T3) and 30 min (T4) after aortic
declamping, 30 min (T5) and 24 hours (T6) after termination of CPB for
determination of plasma malondialdehyde (MDA), creatine kinase MB
(CK-MB), TXB2 and 6-Keto-PGF1 (stable metabolites of TXA2 and
PGI2). Postoperative inotropic support was defined as the use of
dopamine 5 g.kg-1 min-1 for a duration 30 min with or without
concomitant application of epinephrine. Statistical analysis was
S-52
INVERSE CORRELATION BETWEEN OXIDATIVE STRESS 16.4 pg/mL) and Rep-30’ (119.7 ± 19.3 pg/mL), until Rep-120’ (83.6 ±
AND INTERLEULIN-10/INTERLEULIN-6 RATIO IN 18.2 pg/mL). Monocyte production of IL-10 and IL-6 in MESF units
PATIENTS UNDERGOING CARDIOPULMONARY BYPASS are shown (Table 1 ). There was no correlation between oxidant stress
or interleukin production with ACC or CPB. IL-10/IL-6 ratio at Rep-12
AUTHORS: D. M. Ansley1, Z. Xia1, B. S. Dhaliwal1, V. Wu2 hours significantly correlated with postoperative cardiac index
AFFILIATION: 1Centre for Anesthesia & Analgesia, Depts. of (r=0.695, P=0.037) and inversely correlated with logarithmic
Anesthesia, Pharmacology & Therapeutics, University of British concentration of plasma 15-F2t-isoprostane at Rep-10’ (r = -0.8849,
Columbia, Vancouver, BC, Canada, 2Department of Immunology, P=0.0007). The IL-10/IL-6 ratio was exceptionally low (0.26 and 0.27
University of British Columbia, Vancouver, BC, Canada. at Rep-120’ and Rep-12 hours) in one patient who needed prolonged
postoperative inotropic support.
INTRODUCTION: Cardiopulmonary bypass (CPB) is associated with CONCLUSION: Oxidative stress occurs during myocardial ischemia
oxidative stress (1) and increased production of anti- and pro- and the early phase of myocardial reperfusion during CABG surgery.
inflammatory cytokines (2). The relationship between oxidant stress 15-F2t-isoprostane production during early reperfusion is associated
and postoperative cytokine balance is poorly understood. We postulated with postoperative interleukin-10 and interleukin-6 imbalance. This
that postoperative interleukin (IL)-10/IL-6 ratio is influenced by the may be associated with complicated postoperative recovery secondary
extent of oxidative stress evidenced by the production of 15-F2t- to low output syndrome.
isoprostane, a specific marker of in vivo lipid peroxidation. REFERENCE:
METHODS: Following ethics committee approval, 10 patients 1. Anesthesiology 2002;96(1):87-7. 2.Ann Thorac Surg
scheduled for coronary artery bypass grafting (CABG) surgery using 1997;63(1):269-76.
CPB were enrolled. Patients were anesthetized with fentanyl 10-15 ug/
kg and isoflurane 0.5-2% end tidal. Normothermic CPB and Table 1 (Mean ±SEM, *P < 0.05 vs baseline)
intermittent blood:crystalloid cardioplegia were utilized during surgery. Baseline (N) Rep-120 min (N) Rep-12 hours (N)
Central venous blood samples were collected at baseline, 30 min global IL-10 (MESF/cell) 153.2±45.6 8 69.5±16.8* 8 75.6± 24.1 10
myocardial ischemia, 10 (Rep-10’), 30 (Rep-30’), 120 min (Rep-120’) IL-6 (MESF/cell) 3.0± 0.5 10 20.2±8.1* 8 13.8± 9.2 10
and 12 hours (Rep-12 hours) after aortic declamping (reperfusion).
Oxidant stress was determined by enzyme immunoassay of plasma free IL-10/IL-6 ratio 54.0± 15.8 8 18.0±9.6* 8 18.9± 6.3* 10
15-F2t-isoprostane. Molecules of equivalent soluble fluorochrome units
(MESF) of IL-10 and IL-6 in monocytes were measured by flow
cytometry of heparinized whole blood samples taken at baseline, Rep-
120’ and Rep-12 hours. Statistical analysis was performed using
repeated measures of ANOVA. Data was expressed as mean ± SEM.
RESULTS: Seven males and 3 females (age 66.8 ± 2.9 yr) were
studied. Mean pre-operative LVEF was 59.5 ± 3.9%. The aortic
crossclamp (ACC) and CPB time were 118.3 ± 20.5 min, and 156.1 ±
23.2 min, respectively. Baseline plasma free 15-F2t-isoprostane ( 103.4
± 17.9 pg/mL) increased significantly during ischemia (255.8 ± 60.1 pg/
mL, P < 0.01 vs baseline), and remained elevated at Rep-10’ (133.9 ±
S-54 2003; 96; S-1–S-293
S-53
APROTININ PHARMACOKINETICS DURING CARDIO- exact test). No correlation was found between aprotinin levels and
PULMONARY BYPASS IN SMALL PEDIATRIC PATIENTS baseline hemoglobin levels, the amount of blood versus crystalloid
added to the pump prime, weight, or age.
AUTHORS: L. Gramlich, J. S. Kroin, G. Tubic, R. J. McCarthy, K. J. DISCUSSION: The optimal dosing for small pediatric patients has not
Tuman been determined. It has been established that aprotinin dosing in
AFFILIATION: Dept. of Anesthesiology, Rush Medical College, pediatric patients is best calculated on a weight-adjusted basis. A
Chicago, IL. 30,000 KIU/kg load plus 30,000 KIU/kg pump prime failed to achieve
levels > 200 KIU/ml (3). Additional studies including aprotinin blood
INTRODUCTION: Although the pharmacokinetics of aprotinin in concentrations and standardization of dosing regimens will be required
adults has been well established (1), the optimal dosing to produce to define the minimal amount of aprotinin to maintain desired blood
effective levels >200 KIU/ml (2) of this protease inhibitor has not been levels cost-effectively.
established in pediatric patients. The dosing variation utilized in various REFERENCES:
studies makes their comparison difficult. A limited amount of data has (1) Anesth Analg 2000; 91:257.
been reported on aprotinin blood levels in children (3). The goal of this (2) J Thorac Cardiovasc Surg 1993;106:1.
study was to determine in pediatric patients less than 15 kilograms, if (3) Ann Thorac Surg 1998;65:S45.
adequate aprotinin levels were achieved with a predetermined aprotinin (4) Blood Coag Fibrin 2001;12:32.
bolus, maintained during initiation of bypass with a fixed amount of
aprotinin added to the pump prime, and maintained with a constant
infusion throughout the bypass period.
METHODS: Following IRB approval and informed consent, 11
cardiac surgery patients (ages 3mo-3 yr; weight 3.4-12.7 kg) were
enrolled. Aprotinin was administered as a 35,000 KIU/kg load over 20
min before skin incision, an infusion of 25,000 KIU/kg/hr after the load
and continued until skin closure, and an additional 35,000 KIU/kg was
added to the pump prime immediately before initiating bypass. A
baseline blood level was obtained before aprotinin administration.
Subsequent levels were obtained 5 min after the aprotinin load, 5 min
after initiating CPB, every 60 min during CPB, at skin closure, and at 6
and 12 hrs postoperatively. Aprotinin levels were determined using a
functional chromogenic assay (4).
RESULTS: Ten of 11 patients achieved aprotinin blood levels >200
KIU/ml after the loading dose. Nine of 11 patients had levels >200 KIU/
ml throughout the CPB period. The lowest level measured during CPB
was 180 KIU/ml. Children whose pump prime volume (PPV): estimated
blood volume (EBV) was > 2 trended toward lower aprotinin levels
after initiating CPB, while those with PPV: EBV 2 trended toward
increased aprotinin levels after the institution of CPB (p=0.08; Fishers
S-54
THE RAPIDPOINT HEPARIN MANAGEMENT TIME (HMT) IS conventional Celite ACT (Figure). Aprotinin concentration is on
NOT PROLONGED BY APROTININ FOLLOWING HEPARIN logarithmic scale (I µMol is 50 KIU/mL). Baseline HMT of 550(7.1)
DOSES USED PRIOR TO CARDIOPULMONARY BYPASS BUT second increased with all colloids. The prolonged duration with HAES and
IS BY HEMODILUTION WITH COLLOID. gelatin of 28.5(11.8) and 45(13.1) seconds were not statistically significant
from zero (p=0.42 and 0.23 respectively). The rise in HMT with Hextend of
AUTHORS: T. Roche, D. Royston 92(10.9) seconds was significant (p=0.003). These effects were not
AFFILIATION: Royal Brompton and Harefield NHS Trust, Harefield, observed with crystalloid hemodilution
United Kingdom. COMMENTS. These preliminary data suggest that the HMT is not
affected by clinically achieved concentrations of aprotinin when the starting
INTRODUCTION: Aprotinin is an ‘anticoagulant’ protease inhibitor in duration (>400- 480 seconds) is as anticipated following full-dose heparin
vitro leading to the activated coagulation time (ACT) being prolonged administration to patients prior to surgery with cardiopulmonary bypass.
above that produced by heparin alone. Although less likely to occur with The duration of the test is affected by hemodilution with colloids. These
kaolin it is still reported with concentrations of aprotinin (1) measured preliminary data suggest that administration of Hextend may have the most
clinically (2). A point-of-care system (RapidPoint HMT) that uses a clinically relevant effect.
proprietary based activator incorporating Celite and a novel sensing system REFERENCES:
has been introduced to monitor moderate to high doses of heparin during 1.Zucker et al. J Extra-corporeal Technology 1995;27(4):201-7.
surgical and non-surgical procedures. The aim of this study was to 2.Royston et al Anesth Analg 2001;92(4):830-6.
determine by in vivo and in vitro testing if there was an effect of high doses
of aprotinin on this test system and if sample dilution to a hemoglobin
observed clinically affected the assay.
METHODS: With IRB approval blood samples were taken from patients
who had received either a large dose of aprotinin (Royston) or heparin to
obtain a Celite ACT using the ITC Hemochron system and CA 505 tubes of
at least 400 seconds.
When heparin had been administered first aprotinin was added to give a
final concentration of 1, 3 and 10Mol (equivalent to 50,150 and 500 KIU/
mL). In these samples also the hemoglobin was measured and sufficient
colloid as a polygeline (Haemaccell) starch (HAES) or balanced starch
(Hextend) solution were added to reduce the hemoglobin to a value of
about 7 g/dL thus mimicking the effects of hemodilution with bypass. With
prior aprotinin administration heparin 1, 2 and 5 IU / mL were added. Data
are expressed as mean± SEM and analysis was with ANOVA followed by
group comparison using Student-Newman-Keuls if appropriate
RESULTS: All data points represent the mean (SEM) of at least 6
individual results. Values in patient samples with heparin alone (406 (7.8)
sec) did not increase significantly with addition of aprotinin using the
RapidPoint system but there was a significant prolongation with the
2003; 96; S-1–S-293 S-56
S-55
MONITORING PLATELET AGGREGATION DEFECT between TP and aggregometer-derived parameters. Also, the amount of
INDUCED BY CARDIOPULMONARY BYPASS: postoperative bleeding correlated with neither ADP-induced platelet
COMPARISON BETWEEN NOVEL WHOLE BLOOD aggregation nor TP.
AGGREGOMATER AND SONOCLOT ANALYZER CONCLUSION: This preliminary study suggests that whole blood
aggregometer could be more sensitive indicator of platelet function
AUTHORS: E. N. Takagi, Y. Kotake, R. Serita, H. Morisaki, J. Takeda rather than Sonoclot during in the perioperative period of cardiac
AFFILIATION: Keio University, Tokyo, Japan. surgery.
REFERENCES:
INTRODUCTION: Platelet dysfunction has been postulated as a (1) Ann Thorac Surg 1994;57:981
possible cause of postoperative bleeding after cardiopulmonary bypass (2) Thromb Res 2001;101:65
(CPB) (1). However, conventional assay of platelet aggregation has (3) Br J Phamacol 2001;133:1396
several disadvantages. Recent investigations suggest promising (4) Anesth Analg 1998;87:1228
application of intraoperative monitoring of platelet function by screen
filtration platelet aggregometer (WBA analyzer, Mebanix, Japan) (2, 3). Data were expressed as mean ± SD. *p<0.05 versus Preop
Another study reported significant correlation between platelet Preop Endop 1POD
aggregation and a Sonoclot?- (Sienco, USA)-derived parameter; time to
peak (TP) (4). In this prospective, observational study, we analyzed Response to 2µM ADP (%) 31.1±37.7 0.6±2.9* 22.0±30.9
perioperative changes of platelet function with these two methods. Response to 4µM ADP (%) 59.2±42.7 2.3±3.7* 50.8±42.8
METHODS: With IRB approval, 26 adult patients who underwent Response to 8µM ADP (%) 78.5±26.8 13.6±22.2* 70.6±35.0
cardiac surgery under cardiopulmonary bypass participated in this
study. Arterial blood was drawn from arterial catheter at following time Response to 16µM ADP (%) 89.8±11.2 43.3±35.0* 82.1±21.1
points: after anesthetic induction (Preop), at the sternal closure (Endop) PATI (µM) 4.6±3.4 14.1±3.1* 6.0±4.9
and 1POD. Whole blood aggregation was initiated with 2 to 16 µM
TP (min) 15.1±6.6 17.1±7.5 15.5±5.2
ADP and the filtration pressure caused by platelet aggregate was
recorded. Simultaneously, the platelet aggregatory threshold index
(PATI) was automatically calculated as the concentration of ADP
inducing 50% of pressure rate. Sonoclot signature was also recorded
with celite-activated cuvette and TP was recorded manually. Data were
statistically analyzed with Friedman’s non-parametric test and P<0.05
was considered significant.
RESULTS: Data of platelet function from 26 patients (age; 55±15 y/o,
total CPB time: 190±49 min, postoperative chest tube drainage:
652±333ml/24hr) were summarized in the Table.
Platelet aggregation induced by ADP was significantly attenuated after
CPB and returned to Preop level on 1POD, which was confirmed by
increased PATI at Endop. On the contrary, TP did not show significant
change after CPB and 1POD. There were no significant correlation
S-56
DIPHENHYDRAMINE ATTENUATES THE HEMODYNAMIC The effects of diphenhydramine on mean arterial and pulmonary pressures
CHANGES ASSOCIATED WITH PROTAMINE
Diphen – Mean arterial Pulmonary
ADMINISTRATION Time
hydramine pressures pressures
1 2 1
AUTHORS: S. Ramachandran , E. J. Lehning , J. D. Wasnick No Pre- protamine 78.4+/-1.3 23.8+/-0.9
AFFILIATION: 1Albert Einstein College of Medicine/Montefiore No Post-protamine 61.8+/-0.9 24.8+/-0.9
Medical Center, Bronx, NY, 2Montefiore Medical Center, Bronx, NY.
Yes Pre-protamine 79.7 +/- 1.2 20.2 +/- 0.7
INTRODUCTION: Protamine is routinely administered to reverse the Yes Post-protamine 78.8 +/- 1.3 20.2 +/ - 0.9
anticoagulant effects of heparin during cardiac sugery. Administration
of protamine is associated with histamine release often resulting in CONCLUSION: Although limited by its retrospective design, this
tachycardia and/ or hypotension. Some surgeons and anesthesiologists analysis suggests that the routine administration of diphenhydramine
routinely administer diphenhydramine (Benadryl) prior to protamine immediately prior to protamine reversal of heparin anticoagulation
administration in the hope of mitigating any histamine related attenuates histamine-mediated reductions in mean arterial pressures.
hemodynamic changes. This retrospective review was undertaken to REFERENCES:
determine the efficacy of this practice, following approval by 1. J Cardiothorac Anesth 2:225, 1988
institutional authorities. 2. Clin Rev Allergy 1991, 9(3-4): 339-55
METHODS: Intra-operative anesthesia records of 78 patients 3. Anesthesiology clinics of North America Dec 1999, 17(4)
undergoing cardiac surgery with cardiopulmonary bypass and heparin
anticoagulation managed by the same cardiac anesthesiologist between
January, 2001 and December, 2001 were identified. Rate of protamine
administration ( dose completed over ten minutes) and method of
administration (via peripheral IV) were thus standardized according to
the anesthesia provider. 39 patients were pre-treated with 50 milligrams
of diphenhydramine immediately prior to protamine administration.
Patients were given diphenhydramine according to the standard
preferences of the attending surgeons. No selection criteria were
employed to determine which patients would receive diphenhydramine
pretreatment. Likewise, 39 cases of surgeons who do not request the
administration of diphenhydramine were examined. The mean arterial
pressures and the mean pulmonary pressures immediately before and 15
minutes after the administration of protamine were noted for both
groups of patients. The data was analysed using repeated measures
ANOVA.
RESULTS: Administration of diphenhydramine pretreatment
attenuates the decrease in mean arterial pressure associated with
protamine administration.
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SYSTEMIC HYPOTENSION AFTER PROTAMINE this association was expressed as an odds ratio with 95% confidence
ADMINISTRATION IS ASSOCIATED WITH IN-HOSPITAL intervals.
MORTALITY FOLLOWING PRIMARY CABG SURGERY RESULTS: Data were complete for 6846 patients. The mean (+/- standard
deviation) protamine dose was 257mg (+/-95mg) and overall mortality was
AUTHORS: I. J. Welsby, M. F. Newman, B. Philips-Bute, M. 2%. A 20% drop in MAP within 30 minutes after protamine administration
Stafford-Smith occurred in 19% patients and was significantly associated with death, (odds
AFFILIATION: Duke University Medical Center, Durham, NC. ratio 1.85 [1.27-2.7], p< 0.001). Every 120mmHg.min increment in
AUC<100 (=10mmHg decrease in sBP for 12 minutes) significantly
INTRODUCTION: Protamine is universally accepted as essential for increased mortality (p<0.001) by an odds ratio of 1.23 [1.16-1.36]. Figure 1
reversing heparin anticoagulation after coronary artery bypass grafting illustrates the increased probability of death [95% confidence intervals]
(CABG). Varying degrees of systemic hypotension are seen after protamine with increasing AUC<100.
administration and are accepted by most clinicians as unavoidable. DISCUSSION: Systemic hypotension occurs commonly after protamine
However, adverse events following protamine administration have been administration and is independently associated with mortality following
retrospectively linked to poor outcome (1), so we tested the hypothesis that primary CABG, after controlling for preoperative risk. Prospective studies
systemic hypotension after protamine administration is associated with are required to investigate potential mechanisms linking protamine
increased mortality following CABG after controlling for preoperative risk. administration with poor outcome.
METHODS: We examined the computerized anesthesia records (Arkive, REFERENCES:
Arkive Inc.,CA), with 1 minute data recording intervals, for 6921 patients 1) Kimmel SE, Sekeres M, Berlin JA et al. Anesth Analg 2002 94(6):1402-
undergoing primary, elective CABG at Duke University Medical Center 8
between 1993 and 2000. Porcine heparin was administered in a 300-400 2) Hannan EL, Kilburn H, Racz M et al. Jama. 1994;271(10):761-6.
units/kg bolus and the ACT maintained at >480 seconds. Protamine was
administered until the ACT returned to baseline or the ratio of
1mg:100units heparin was reached. Systemic hypotension was defined as a
20% decrease in systemic mean arterial pressure (MAP) within 30 minutes
after protamine administration compared to a baseline defined as the
median MAP for the 5 minutes prior to protamine . A degree-duration
integral of hypotension was also calculated from the area under the curve
(AUC) of systolic blood pressure (sBP) <100mmHg over this 30 minute
period (AUC<100) to associate the severity of hypotension with mortality.
The AUC<100 was plotted against predicted probability of mortality,
including 95% confidence intervals (Figure 1). For example, a sBP of 80
mmHg for 15 minutes would equal a AUC<100 of 300mmHg.min; an
AUC of 1200 is equivalent to sBP = 60mmHg for 30 minutes.
Contemporaneously calculated Hannan scores (2), were included to control
for preoperative risk of death. In-hospital mortality was the primary
outcome variable. Multivariate logistic regression models included the
above variables as predictors to test for association with outcome (death);
S-58
FACTOR V LEIDEN PROTECTS AGAINST BLOOD LOSS AND factors. Our study is the first to report a significant, independent
TRANSFUSION FOLLOWING CARDIAC SURGERY protective effect of FVL on postoperative blood loss and transfusion.
Future investigations to evaluate FVL as a possible thrombotic risk factor
AUTHORS: B. S. Donahue, D. Gailani, A. L. George, Jr in this population are warranted.
AFFILIATION: Vanderbilt University, Nashville, TN. REFERENCES:
1. Sweeney, J. D., Blair, A. J., Dupuis, M. P., King, T. C. & Moulton, A.
INTRODUCTION: The impact of genetic variation on cardiac surgery L. (1997) Transfusion 37, 1173-8.
outcome has not been systematically explored. Many have implied that 2. Ong, B. C., Zimmerman, A. A., Zappulla, D. C., Neufeld, E. J. &
factor V Leiden (FVL) may decrease hemorrhagic risk (1), or increase Burrows, F. A. (1998) Can J Anaesth 45, 1176-80.
thrombotic risk (2-4), but clinical studies addressing this issue have 3. Moor, E., Silveira, A., van't Hooft, F., Tornvall, P., Blomback, M.,
frequently been underpowered. Here, we characterize the impact of FVL Wiman, B., Ryden, L. & Hamsten, A. (1998) Thromb Haemost 80, 220-4.
on blood loss and transfusion, using regression techniques in a population 4. Fanashawe, M. P., Shore-Lesserson, L. & Reich, D. L. (2001)
of cardiac surgery patients. Anesthesiology 95, 1525-7.
METHODS: We prospectively enrolled 517 cardiac surgery patients and 5. Ridker, P. M., Hennekens, C. H., Lindpaintner, K., Stampfer, M. J.,
evaluated the impact of FVL on blood loss and transfusion. Chest-tube Eisenberg, P. R. & Miletich, J. P. (1995) N Engl J Med 332, 912-7.
output was measured at 6 and 24 hours after ICU arrival, and transfusion
of blood components was recorded from time of operating room entry
until discharge. Patient DNA was tested for FVL by MnlI restriction
fragment length (5). Univariate analysis of chest tube output employed t-
test for independent samples. Multivariate analysis consisted of linear
regression of known clinical variables, including FVL, on the dependent
variables of blood loss and units of blood product transfusion. Logistic
regression was performed using the same independent variables, and risk
of receiving transfusion during hospitalization as the dependent variable
(transfused vs not transfused).
RESULTS: For the 26 FVL carriers, mean blood loss at 6 and 24 hours
was significantly less than that of noncarriers (see Figure; 238cc vs
358cc, and 522cc vs 730cc, respectively; p<0.001). Using linear
regression, accounting for ethnicity and variables known to affect blood
loss, FVL was a significant independent contributor at both time points
(p=0.004 and 0.007, repectively). No effect of FVL was observed using
similar linear regression approaches on units of blood components
transfused. However, multivariate logistic regression of risk for receiving
any transfusion, which controlled for confounding variables including
ethnicity, demonstrated that FVL exerted a significant protective effect
(p=0.010).
DISCUSSION: Current inferences regarding FVL in cardiac surgery are
provocative, yet inconclusive, and do not characterize contributing
2003; 96; S-1–S-293 S-60
S-59
ELEVATED PLASMA CONCENTRATONS OF THE MATURE tension and saturation of hepatic venous blood were significantly
FORM OF ADRENOMEDULLIN DURING CARDIAC decreased during CPB. Plasma AM-m concentrations sampled from the
SURGERY AND HEPATOSPLANCHNIC HYPOPERFUSION hepatic vein showed a significant negative correlation with oxygen
tension and saturation at 10 min and 60 min after the onset of CPB.
AUTHORS: D. Yoshikawa1, F. Kawahara1, Y. Kadoi1, F. Goto1, N. DISCUSSION: AM is produced from its precursor by a two-step
Okano2, T. Morita2 enzymatic reaction. First, the AM precursor is converted to glycine-
AFFILIATION: 1Department of Anesthesiology and Reanimatology, extended AM-Gly. Subsequently, AM-Gly is converted to active,
Gunma University School of Medicine, Maebashi, Japan, 2Department mature AM (AM-m), by enzymatic amidation. The AM-m/AM-T ratio
decreased during CPB, suggesting that production of the intermediate
of Anesthesiology, Saitam Cardiovascular and Pulmonary Center, form of AM, AM-Gly, is greater than AM-m. The plasma AM-m
Osato-gun, Saitama, Japan. concentration and the ratio of AM-m/AM-T in blood from the hepatic
INTRODUCTION: Adrenomedullin is a potent vasodilatory peptide. vein were significantly higher than those from the radial artery or
Plasma adrenomedullin (AM) concentrations increase during and after jugular bulb. Furthermore, oxygen tension of hepatic vein was
cardiopulmonary bypass (CPB). However, the cause of this elevation selectively decreased during CPB and plasma AM-m concentrations
and its site of production have not been identified. We investigated the sampled from the hepatic vein showed a significant negative correlation
role of the hepatosplanchnic and cerebral circulations in the elevation of with oxygen tension. These data suggest that the hepatosplanchnic
plasma AM, and whether tissue hypoxygenation is a cause of the AM circulation is an important source of AM-m during CPB. Furthermore,
elevation seen during CPB. hypoxygenation of the hepatosplanchnic region may be an important
METHOD: We measured plasma total AM (AM-T) and the cause of this AM-m elevation.
biologically active form of AM, AM-mature (AM-m), in 7 patients
undergoing normothermic CPB. Anesthesia was induced with
midazolam (0.2 mg/kg) and fentanyl (5 mcg/kg) and maintained with
15 mcg/kg fentanyl, 4 mg/kg/h propofol and 50% oxygen. Blood
samples were obtained from the radial artery, the hepatic vein, and the
jugular bulb simultaneously. Both AM-m and AM-T were measured by
radioimmunoassay using commercially available kits (AM mature RIA
Shionogi and AM RIA Shionogi; Shionogi Co., Osaka, Japan). Plasma
concentrations of AMs were analyzed by two-way analysis of variance
for repeated measures followed by Sheffe's test. Correlations between
concentrations of AMs and oxygen tension or saturation were analyzed
by calculating Pearson's correlation coefficients. A P value less than
0.05 was considered statistically significant.
RESULTS: Both plasma AM-T and AM-m concentrations increased
significantly 60 min after weaning from CPB. The plasma AM-m
concentration and the ratio of AM-m/AM-T in blood from the hepatic
vein were significantly higher than those from the radial artery or
jugular bulb. The AM-m/AM-T ratio decreased during CPB. Oxygen
S-60
DISSOCIATION BETWEEN REGIONAL CEREBRAL AND decrease in rSO2 (the lowest values of 39±7%) and the increase in SjO2
JUGULAR VENOUS OXYGEN SATURATION IN (highest value of 81±9%) were similar to those in CPB group. rSO2
CARDIOVASCULAR SURGERY WITH HYPOTHERMIC decreased below 40% in six patients in CPB group and in three patients
CARDIOPULMONARY BYPASS in SCP group. Neurological complication (cerebral infarction in right
MCA region) was seen in one patient in SCP group, who showed
AUTHORS: K. Ishida, K. Ohtake, T. Gohara, Y. Morimoto, M. decrease in rSO2 (<40%) with side to side difference (left/ right=46/
Matsumoto, T. Sakabe 24%). The patient developed right hemiplegia postoperatively.
AFFILIATION: Department of Anesthesiology –Resuscitology, DISCUSSION: Dissociation between rSO2 and SjO2 occurred in the
Yamaguchi University School of Medicine, Ube, Japan. present study. The dissociation appeared to be mostly attributed to a
temperature reduction. Reduction in rSO2 is well compatible to the
INTRODUCTION: Both regional cerebral (rSO2) and jugular venous results of recent report that demonstrated the reduction of the brain
oxygen saturation (SjO2) have been used to monitor cerebral tissue PO2 during hypothermic therapy in head injured patients1). In the
oxygenation and to predict neurological complications during present study, only one of 9 patients who showed decreased rSO2
cardiovascular surgery. However, there have been few reports that (<40%) developed neurological complication, in whom SjO2 (ipsilateral
examined the changes of both parameters simultaneously. The purpose
of this study is to examine the concomitant changes of rSO2 (measured to infarct side) did not show a detectable decrease but showed side to
side difference in rSO2. Although the critical level of rSO2 at which
at right and left forehead using INVOS 4100) and right SjO2
neurological complication occurs has not been established, meticulous
(intermittent sampling), and to evaluate whether these parameters are care must be exercised when rSO2 decreased below 40% with side to
useful to predict neurological complications.
METHODS: Eighteen patients were studied: 11 patients underwent side difference greater than 10%.
coronary artery bypass graft surgery under conventional Reference: 1).Br J Anaesth 2002 88 188-92.
cardiopulmonary bypass (CPB group) and 7 patients underwent
thoracic vascular surgery under CPB with selective cerebral perfusion
(SCP group). Anesthesia was maintained with fentanyl (30ug/kg),
midazolam (0.4mg/kg) and isoflurane (0.5-1%). CPB was established
with a pump flow of 2.2-2.4 L/m2/min at 32C(esophageal temperature).
SCP was established with a pump flow of 10ml/kg/min at 21C. The
values of rSO2 and SjO2 were measured simultaneously. All patients
were neurologically assessed postoperatively.
RESULTS: In both groups, the mean values of rSO2 (left/right=56±6/
54±8%) were approximate to the values of SjO2 (54±11%) after
anesthetic induction. In CPB group, the mean values of rSO2 decreased
during aortic clamp (32.6±0.7C), returning to prebypass values after the
termination of CPB. The mean values of SjO2 were increased, the
highest values being 71±8%. There were significant differences
between rSO2 and SjO2 during hypothermic period. In SCP group, the
2003; 96; S-1–S-293
S-61
SLOW REWARMING IMPROVES JUGULAR VENOUS
OXYGEN SATURATION DURING REWARMING PERIOD
AUTHORS: F. Kawahara1, Y. Kadoi2, S. Saito1, F. Goto1
AFFILIATION: 1Gunma University, Maebashi, Gunma, Japan,
2
Division of Intensive Care Unit, Gunma University, Maebashi, Gunma,
Japan.
BACKGROUND: There have been many studies regarding the
etiology of postoperative cognitive dysfunction after CABG surgery.
Although its etiology remains unresolved, one possible factor related to
postoperative cognitive dysfunction is a reduced internal jugular venous
oxygen hemoglobin saturation (SjvO2) during rewarming period. The
purpose of this study was to examine the effect of rewarming rates on
SjvO2 during rewarming period.
METHODS: One-hundred patients scheduled for elective coronary
artery bypass graft (CABG) surgery were randomly divided into two
groups; control group (0.48+/-0.09 degree) (n=50), slow rewarming
group (0.24+/-0.09 degree)(n=50). After the induction of anesthesia,
fiberoptic oximetry oxygen saturation catheter was inserted into the
right jugular bulb to monitor SjvO2 continuously. Hemodynamic
parameters, arterial and jugular venous blood gases were measured at
nine time points.
RESULTS: Cerebral desaturation (defined as a SjvO2 value below 50
% ) during rewarming period was more frequent in control group than
in slow group. Cerebral desaturation time (duration when SjvO2 was
less than 50 %) and the ratio of the cerebral desaturation time to the
total CPB time in control group were significantly differed from those
in slow group (control group: 17+/-11 min, 12+/-4 %, slow group: 10+/
-8 min, 7+/-4 %, respectively, p<0.05). There was no significant
difference in mini-mental state examination at the day before the
operation and at one month after the surgery between four groups (At
the day before the operation: control group;48+/-8, slow group;48+/-7,
at one month after the surgery:control group;46+/-7, slow group;45+/-
9).
CONCLUSIONS: Slow rewarming rate could prevent the frequency of
the decrease in SjvO2 during rewarming period.
Critical Care
and Trauma
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REDUCING BLOOD LOSS DURING BIMAXILLARY REFERENCES:
OSTEOTOMY: CASE SERIES OF HYPOTENSIVE 1. J Oral Maxillofac Surg 1996;54:21-4.
ANESTHESIA 2. Br J Oral Maxillofac Surg 2001;39:365-70.
3. J Maxillofac Surg 1973;1:213-21.
AUTHORS: J. J. Pandit1, M. Dobson1, R. Rogers1, N. Saeed2, P.
Carls2
AFFILIATION: 1Nuffield Department of Anaesthetics, Oxford, United
Kingdom, 2Department of Oral and Maxillofacial Surgery, Oxford,
United Kingdom.
INTRODUCTION: As many as one third of patients undergoing
bimaxillary surgery will require blood transfusion (1). Numerous
methods have been used to reduce perioperative bleeding, including the
use of hypotensive anesthesia, auto-transfusion and hemo-dilution (1,2).
Recently (2), aprotinin has been shown to reduce blood loss (from 986
ml in controls to 473 ml in 15 patients with aprotinin). However, in this
study, 9 patients in the control group required blood transfusion. The
levels of blood loss in "control’ groups reported in the literature seemed
to us to be high, and the purpose of this study was to assess the efficacy
of simpler techniques to minimise transfusion requirements.
METHODS: We report a prospective study of 20 consecutive patients
who underwent bimaxillary surgery under one surgical-anesthetic team.
General blood saving techniques involved: 1. hypotensive anesthesia
(using high dose isoflurane and where necessary, labetolol); 2. high
head-up position during surgery; 3. application of local vasoconstrictors
(bupivacaine/1:200,000 epinephrine); 4. meticulous surgical dissection
according to the method of Obwegeser and Sailer (3).
RESULTS: The median blood loss was 373 ml (range 160-800 ml).
There were no adverse events in the group. Only one patient needed
blood transfusion, and this was because of severe epistaxis flowing
nasotracheal extubation.
CONCLUSIONS: In the majority of cases, it appears possible to
reduce blood loss and transfusion requirements to minimal levels using
a simple combination of careful anesthetic and surgical techniques.
Complex and expensive interventions might reasonably be reserved for
those particular patients initially thought to be at greater risk of
haemorrhage (eg, due to coagulopathy).
S-63
COMPARISON OF THE EFFECTS OF PROPOFOL AND REFERENCES:
ENFLURANE IN THE CORRECTIVE SURGERY OF 1) Flaishon R, Windsor A, Sigl J, et al. Recovery of consciousness after
SCOLIOSIS WITH THE POSTERIOR INSTRUMENTATION thiopental or propofol: bispectral index and the isolated forearm
technique. Anesthesiology 1997; 86: 613-619
AUTHORS: Q. Fan, H. Cai, Y. Liang, B. Yu 2) Leslie K, Sessier D, Smith WD, et al. Prediction of movement during
AFFILIATION: Rui Jin Hospital, Shanghai, China. propofol/nitrous oxide anesthesia. Anesthesiology 1996; 84: 52-63.
INTRODUCTION: To study the propofol dose in anesthesia induction Table Comparison of the time of peri-operative in four groups (`m±SD)
and maintenance infusion rate for the corrective surgery of scoliosis Awaking test Postoperative Orientation Nausea and
with the posterior instrumentation and to compare the effects of time awaking recovery time vomiting
propofol in awaking test time and induced hypotension with enflurane.
(min) time (min) (min) incidence(%)
METHODS: Forty-eight scoliosis patients undergoing general
anesthesia were randomly divided into two groups (group A and group Group Ai 9.60±3.40 15.25±5.75 18.60±5.55 5.88±1.26
B). Group A and group B were re-divided into four sub-groups in Group Aii 9.82±2.90 16.40±4.90 19.60±6.50 5.45±1.35
accordance with age: group Ai (under 12 years) and group Aii (above 12
years); group Bi (under 12 years) and group Bii (above 12 years). All Group Bi 20.80±3.60** 24.10±8.60* 27.50±4.20* 37.86±4.50**
groups were induced with fentanyl, propofol and atracurium. The Group Bii 22.90±4.05 **
25.25±7.50 *
26.45±5.75 *
35.20±4.30**
anesthesia was maintained with an infusion of either propofol and 50% *
N2O-O2 in group Ai and group Aii or enflurane and 50% N2O-O2 in P value < 0.05 , Group Bi vs Group Ai; Group Bii vs Group Aii, **P value
group Bi and group Bii. The HR, MAP, SpO2, BIS and SEF were < 0.01, Group Bi vs Group Ai; Group Bii vs Group Aii
monitored intraoperatively(1).
RESULTS: The induction dose of propofol was 2.88±0.25 mg·kg-1 in
children and 1.56±0.38 mg·kg-1 in adult. The maintenance infusion rate
of propofol was 10.35±1.65 mg·kg-1·h-1 in children and 8.40±2.25
mg·kg-1·h-1 in adult. The maintenance of enflurane level was 2.10±0.34
MAC in children and 1.22±0.32MAC in adult. Awaking test time,
postoperative awaking time, orientation recovery time(2) and the
vomiting incidence in group Ai and group Aii were much lower than
those in group Bi and group Bii (Table). The induced hypotension of the
group Ai and group Aii was also better than that of group Bi and group
Bii.
SUMMARY: Propofol is a proper anaesthetic for the corrective surgery
of scoliosis with the posterior instrumentation.
2003; 96; S-1–S-293 S-65
S-64
A COMPARISON OF EFFECTS OF PERIOPERATIVE CONCLUSION: Laparoscopic cholecystectomy is better than that of
PULMONARY FUNCTION IN LAPAROSCOPIC AND the same procedure performed via laparotomy in elderly patients with
LAPAROTOMIC CHOLECYSTECTOMY IN ELDERLY mild or moderate pulmonary dysfunction.
PATIENTS REFERENCES:
(1) Oikkonen M, Tallgren M. Changes in respiratory compliance at
AUTHORS: Q. Fan, M. Ji, L. Chen, H. Cai, B. Yu
laparoscopy: measurements using side stream spirometry. Can J
AFFILIATION: Rui Jin Hospital, Shanghai, China. Anaesth, 1995,42: 495-502;
INTRODUCTION: To compare the effects of perioperative pulmonary (2) Makinen MT, Yli HA. The effect of laparoscopic cholecystectomy
function in laparoscopic and laparotomic cholecystectomy in elderly on respiratory compliance as determined by continuous spirometry. J
patients. Clin Anesth, 1996, 8:119-125.
METHODS: One hundred and twenty patients suffering from
cholecystitis and undergoing laparoscopic or laparotomic
cholecystectomy were divided into two groups on the basis of the
normal or abnormal pulmonary function. A standardized general
anesthetic technique was used for all patients. All pulmonary function
parameters were monitored during the operation to compare the effects
of pulmonary function in either laparoscopicor or laparotomic
cholecystectomy (1,2).
RESULTS: (1) In laparoscopic groups with normal and abnormal
pulmonary function, the end tidal carbon dioxide pressure (PetCO2 ),
airway peak pressure (Ppeak), airway plat pressure (Pplat), and arterial
carbon dioxide pressure (PaCO2 ) were increased (14.5%, 45.1%,
60.0% and 18.5% respectively) during the peritoneal insufflation,
whereas, both respiratory compliance (C) and pH value (pH) were
decreased significantly (42.0% and 2.7%) as compared with the pre-
insufflation value (p<0.01). After deflation of peritoneal cavity, the
PetCO2, Ppeak, Pplat, C, pH, and PaCO2 recovered to pre-insufflation
level. (2) In laparotomic groups with normal or abnormal pulmonary
function, no striking difference could be found during and after
laparotomy in PetCO2, Ppeak, Pplat, C, pH, and PaCO2. (3) Between
laparoscopic groups and laparotomic groups, striking difference was
found during the operation, but not after the operation. (4) The
postoperative pulmonary complications were much more and
hospitalization was much longer in laparotomic groups than that of in
laparoscopic groups.
S-65
COMPARISON OF THE ANAESTHETIC METHODS OF minutes respectively. The times to full orientation in Groups A, B and C
MEDIUM-FLOW, LOW-FLOW CLOSED CIRCUITS AND were 24.5 + 6.1 minutes, 17.4 + 5.5 minutes and 12.7 + 4.8 minutes
LOW-FLOW CLOSED CIRCUITS COMBINED WITH respectively. The times to regain consciousness and full orientation in
BISPECTRAL INDEX MONITORING FOR THE USE OF Group C were less than that of Group A (P<0.01) and Group B
(P<0.05). The incidence of nausea and vomiting in Groups A, B and C
SEVOFLURANE was 14.5% + 2.6%, 10.1% + 2.3% and 7.5% + 2.1% respectively. The
AUTHORS: Q. Fan1, R. Eltringham2, R. Craven2, B. Yu1 incidence of nausea and vomiting in Group C was lower than that of
AFFILIATION: 1Rui Jin Hospital, Shanghai, China, 2Gloucestershire Group A (P<0.01) and Group B (P<0.05).
DISCUSSION: Low-flow closed circuit anaesthesia, combined with
Royal Hospital, Gloucester, United Kingdom.
bispectral index monitoring has the advantages of the lowest
INTRODUCTION: The aim of this study was to establish which consumption of sevoflurane, the shortest time to regain consciousness
anaesthetic method provides the best conditions for the use of and the lowest incidence of nausea and vomiting. It was shown to be an
sevoflurane by comparison between medium-flow closed circuit excellent method for the administration of sevoflurane with important
anaesthesia (MFCCA) and low-flow closed circuit anaesthesia financial considerations.
(LFCCA) and low-flow closed circuit anaesthesia combined with REFERENCE:
bispectral index (BIS) monitoring. (1) Flaishon R, Windsor A, Sigl J, et al. Recovery of consciousness
METHODS: Ninety-six ASA I-II patients presenting for elective low after thiopental or propofol: bispectral index and the isolated forearm
abdominal or pelvic surgery under general anaesthesia were randomly technique. Anesthesiology 1997; 86: 613-619
divided into three groups, according to the anaesthetic system used.
Group A, used medium-flow closed circuits, Group B, low-flow closed
circuits and Group C, low-flow closed circuits combined with bispectral
index monitoring. There were 32 patients in each group. Fresh gas flow
was delivered at a rate of 1000ml per minute in Group A and 500ml per
minute in groups B and C. Sevoflurane was delivered through a
Komesarroff vaporizer, which was placed on the inspiratory limb of the
circle. The delivered concentration of sevoflurane from the
Komesarroff vaporizer in Groups A and B, was adjusted as clinically
indicated, while in Group C, it was adjusted according to the BIS value
(at 46 + 10)(1).
RESULTS: End-tidal sevoflurane concentrations in groups A, B and C,
were 1.4 + 0.2MAC, 1.1 + 0.2MAC and 0.8 + 0.2MAC respectively.
Consumption of sevoflurane in groups A, B and C was 13.3 + 1.6 ml
per hour, 9.6 +1.5 ml per hour and 7.5 + 1.8ml per hour respectively.
The end-tidal sevoflurane concentration and the consumption of
sevoflurane in Group C was less than that of Group A (P<0.01) or
Group B (P<0.05). The times to regain consciousness in Groups A, B
and C were 14.3 + 3.3 minutes, 10.5 + 2.8 minutes and 7.5 + 2.6
S-67 2003; 96; S-1–S-293
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BISPECTRAL INDEX MONITORING IN MECHANICALLY DISCUSSION: This study suggests that the depth of sedation
VENTILATED CRITICALLY ILL PATIENTS maintained in our patients was greater than that necessary to provide
adequate hypnosis. The use of objective measure (e.g., BIS monitoring)
AUTHORS: G. P. Joshi1, B. Ogunnaike1, W. Conner1, J. Brock2 to assess the depth of sedation should avoid excessive sedation, which
AFFILIATION: 1University of Texas Southwestern Medical Center at may facilitate ventilatory weaning, and reduce the ICU stay and costs.
Dallas, Dallas, TX, 2Parkland Health and Hospital Systems, Dallas, TX. REFERENCES:
1. Anesthesiology 2000; 93: 1336-44.
INTRODUCTION: Critically ill patients in the intensive care unit
(ICU) requiring mechanical ventilation experience anxiety and
discomfort which may have detrimental physiological consequences,
and can cause agitation and psychosis. Therefore, these patients receive
sedative-hypnotics to improve patient comfort. Clinical scores used to
assess the depth of sedation in this patient population are subjective and
inadequate. The bispectral index (BIS) derived from the
electroencephalograph (EEG) has been shown to be a quantifiable
measure of the depth of sedation (1). This study examined the depth of
sedation, as determined by BIS monitoring, maintained in mechanically
ventilated ICU patients at our institution.
METHODS: Thirty-five mechanically ventilated ICU patients without
any central neurological injury were included in this study. The sedation
regimen was similar in all patients. The hypnotic-sedatives drugs (i.e.,
lorazepam and midazolam) were titrated to maintain a modified
Ramsay score of 4-5. The modified sedation score was as follows:
1=anxious, agitated, restless; 2=cooperative, oriented, tranquil;
3=drowsy, responds to commands only; 4= brisk response to shaking or
loud sound; 5= sluggish response to shaking or loud sound; and 6=no
response. In addition, BIS values were recorded hourly for 8 h but the
nurse caring for the patient was blinded to the BIS values. The BIS
values between 65 and 85 were considered to be appropriate for
sedation (1). Data were analyzed using Students’ t-test or Chi-square
test with Yates’ correction, with p< 0.05 considered significant.
RESULTS: The BIS values were recorded at 204 time points and
ranged between 30 and 95. Of these time points, BIS was maintained
between 65 and 85 in 28% (57/204) instances. In 12% (25/204)
observations, the BIS values were greater than 85 while in 60% (122/
204) of the times the BIS values were lower than 65.
S-67
SEDATION IN MECHANICALLY VENTILATED CRITICALLY 61% had BIS of less than 65 and 12% had BIS of greater than 85. The
ILL PATIENTS: USE OF BISPECTRAL INDEX MONITORING sedation score of 6 was noted at 74/204 (36%) time points with BIS less
than 65 at 73% of time points.
AUTHORS: B. Ogunnaike1, G. P. Joshi1, W. Conner1, J. Brock2 DISCUSSION: These data suggests that significant number of patients
AFFILIATION: 1University of Texas Southwestern Medical Center at were maintained at deeper than necessary depth of sedation. There was
Dallas, Dallas, TX, 2Parkland Health and Hospital System, Dallas, TX. no correlation between sedation scores of 4-5 and the BIS values 65-85
which were considered as adequate sedation. Our results are similar to
INTRODUCTION: Critically ill patients in the ICU requiring Frenzel et al (2) who reported a mean BIS value of 57 for a modified
mechanical ventilation experience anxiety and discomfort that may Ramsay score of 4-5 while a mean BIS of 44 had a score of 6. Use of
have detrimental physiological consequences, and can cause agitation objective measure to assess the depth of sedation should avoid
and psychosis. Therefore, these patients receive sedative-hypnotic excessive sedation, which may facilitate ventilatory weaning, and
medications administered according to clinical sedation scores. reduce the ICU stay and costs.
However, the sedation scores used to assess the depth of sedation are REFERENCES:
subjective and inadequate. The bispectral index (BIS) derived from the 1. Anesthesiology 2000; 93: 1336-44.
electroencephalograph (EEG) has been shown to be an objective 2. Intensive Care Med 2002; 28: 178-183
measure of the depth of sedation (1). This study examined the value of
BIS monitoring in assessing the depth of sedation in mechanically
ventilated ICU patients, compared with clinical sedation scores.
METHODS: Thirty-five mechanically ventilated ICU patients without
any central neurological injury were included in this study. The sedation
regimen was similar in all patients. The hypnotic-sedatives drugs (i.e.,
lorazepam and midazolam) were titrated to maintain a modified
Ramsay sedation score of 4-5. The modified sedation score was as
follows: 1=anxious, agitated, restless; 2=cooperative, oriented, tranquil;
3=drowsy, responds to commands only; 4= brisk response to shaking or
loud sound; 5= sluggish response to shaking or loud sound; and 6=no
response. In addition to sedation scores, BIS values were recorded
hourly for 8 h but the nurse caring for the patient was blinded to the BIS
values. The BIS values between 65 and 85 were considered to be
appropriate for sedation (1). Data were analyzed using Students’ t-test
or Chi-square test with Yates’ correction, with p< 0.05 considered
significant.
RESULTS: The sedation scores and BIS values were recorded at 204
time points and ranged between 30 and 95. The sedation scores were 1-
3 at 38/204 (19%) of the instances. Of these the BIS values were greater
than 85 at 24% of the times. The sedation scores were 4-5 at 92/204
(45%) of the times with BIS values of 65-85 at 27% instances while
2003; 96; S-1–S-293 S-69
S-68
CEREBRAL OXYGEN METABOLISM AND TRANSCRANIAL cerebral hyperemia were found in 44.4% and 59.1% of patients with GOS
DOPPLER ULTRASONOGRAPHY MONITORING IN NEURO- 3-2 and GOS 1 respectively. Daily physiological patterns are shown in
SURGICAL COMATOSE PATIENTS WITH UNFAVORABLE Table 1.
OUTCOME
Daily Physiological Patterns for Patients with Unfavorable Outcomes.
AUTHORS: G. Toma1, V. G. Amcheslavski2, S. V. Madorsky2, D. S. Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
DeWitt1 Group I
AFFILIATION: 1The University of Texas Medical Branch, Galveston, GCS 6.1± 0.6 5.8± 0.5 6.0± 0.6 6.4± 0.7* 6.4± 0.7* 6.1± 0.7 6.8± 0.8*
TX, 2Burdenko Neurosurgical Institute of RAMS, Moscow, Russian SjO2 (%) 54.0± 6.9 59.2± 3.5* 63.6± 4.5 63.5± 3.6 67.7± 3.6 67.4± 3.3 67.9± 3.3 66.2± 4.5
Federation. CEO2 (%) 41.9± 5.7 39.4± 3.5* 32.7± 4.7 35.1± 3.5 30.3± 3.9 30.5± 3.4 31.3± 4.6 32.8± 4.9
AVDO2
INTRODUCTION: Despite the implementation of aggressive strategies (ml/dl)
8.4± 1.5* 5.6± 0.8 5.0± 0.7 5.3± 0.6* 4.9± 0.8* 4.7± 0.6 4.2± 0.5 5.5± 0.8*
of diagnosis and treatment based on the control of ICP, the incidence of FV (cm/
mortality and severe disability in neurosurgical comatose patients sec)
195± 43 165± 28 203± 17 149± 19 172± 16 182± 25 213± 33 171± 17
remains frustratingly high.1 Cerebral oxygen metabolism monitoring and Group II
TCD ultrasonography have become the most useful bed-sited methods for 4.8±
diagnosis, evaluation and prognosis of patients with cerebral hypoxia/ GCS 6.6± 0.5 6.0± 0.5 5.2± 0.4#
0.4*#
4.8± 0.5*# 4.9± 0.5# 4.9± 0.6*#
ischemia and relative cerebral hyperperfusion.2 We examined the SjO2 (%) 60.2± 5.4 67.9± 2.8* 67.7± 4.2 71.3± 4.9 72.8± 5.3 64.1± 5.0 69.3± 7.3 69.0± 5.8
incidence of oligemic cerebral hypoxia (SjO2 <55%) and cerebral
CEO2 (%) 38.5± 6.1 29.7± 2.8* 30.0± 4.1 27.7± 4.8 25.6± 5.1 34.7± 4.9 29.7± 7.1 29.9± 5.6
hyperperfusion (SjO2 >75%) in neurosurgical comatose patients with poor
AVDO2
outcome. 6.8± 1.2* 5.4± 0.5 4.8± 0.6 4.0± 0.7* 3.6± 0.8* 5.0± 1.0 4.0± 1.0 4.3± 0.7*
METHODS: Jugular bulb oxyhemoglobin saturation (SjO2), cerebral (ml/dl)
extraction of oxygen (CEO2), arteriojugular oxygen content difference FV (cm/
206± 22 218± 22* 224± 19 222± 22* 241± 20* 246± 20* 213± 17 216± 20*
sec)
(AVDO2) and middle cerebral artery (MCA) systolic flow velocity (FV)
using TCD were monitored in 56 patients with unfavorable outcome in All dates are mean± SEM, *p<0.05 between groups; #p<0.05 in the same
our NICU. All patients were ventilated, positioned in bed with group
approximately 30-degree head tild, sedated and treated aggressively to DISCUSSION: These results demonstrate that cerebral oligemic hypoxia
keep ICP < 20 mm Hg and CPP >60-70 mm Hg (with vasopressors if and relative cerebral hyperemia are very common events in neurosurgical
needed). Patients were divided in two groups: group I- severe disability/ comatose patients with unfavorable outcome. Concomitant decreases in
vegetative state (GOS 3-2, 16M/5F, 37.6yo) and group II-dead (24M/11F, CEO2 and increases in cerebral FV, indicating hyperoxic uncoupling
39.2yo). 37.5% of patients were operated because of aneurysmal SAH, between global cerebral consumption of oxygen and CBF, are very poor
28.7% had severe TBI, 12.5% had intracerebral hemorrhage, 14.2% had prognostic events and are significantly more pronounced in the
complicated tumor surgery and 7.1% of patients had global cerebral nonsurvival group.
hypoxia during episodes of massive cerebral air embolism. REFERENCES:
RESULTS: Multiple jugular venous desaturations were found in 66.7% 1. New Horizons 3: 366-75, 1995
and 36.4% of patients of group I and II respectively. Episodes of relative 2. Crit Care Med 26: 344-51, 1998
S-69
EFFECT OF MIDAZOLAM ON EXPRESSION OF REFERENCES:
NEUTROPHIL ADHESION MOLECULES CD11B & CD18 IN 1. Daniela M. Zisterer. Gen Pharmac. 1997: 39(3): 305-314.
VITRO 2. M Weiss, N.Mirow. British Journal of Anaesthesia 1993; 70: 317-
321.
AUTHORS: K. Ghori, D. C. Harmon, K. Ullrich, L. Wei, F. Walsh, G. 3. Hiroshi Ichikawa. Cirulation 1997; 81: 922-931.
D. Shorten
AFFILIATION: Cork University Hospital, Cork, Ireland.
INTRODUCTION: The benzodiazapenies are commonly used in
clinical practice, with established anxiolytic effects. The presence of
benzodiazepine receptors has been observed on many immune cells (1)
including neutrophils and the binding of benzodiazepine drugs has been
shown to play an important role in decreasing the release of cytotoxic
reactive oxygen species (2). Neutrophil adhesion molecules play an
important role in the neutrophil-endothelial interaction (3). The
objective of this study was to examine the effect of midazolam on the
expression of neutrophil adhesion molecules (CD11b & CD18).
METHODS: The expression of neutrophil CD11 & CD18 molecules
after exposure to different concentrations midazolam (0, 0.5,1,10 times
of therapeutic plasma concentrations (300 ng/ml) for 30 min at 37ºC
was compared with that of time-matched controls. Aliquots of each
group were stimulated with N-formyl-methionyl-leucyl-phenylalanine
(fMLP) (10 nM) for 15 min at 37ºC to assess differences in the
upregulation of CD11b & CD18. The expression of adhesion molecules
was measured by flow-cytometry. Data is given as mean channel
flurescence (MCF).
RESULTS: The expression of neutrophil CD11b & CD18 was
decreased by pretreatment with midazolam when compared to control
{(92 vs 162)(P=0.03) and (43 vs 53)(p=0.01)} respectively at
therapeutic plasma concentration. There was no further decreased
expression of these molecules at higher drug concentrations.
DISCUSSION: This study demonstrates the inhibitory effect of
midazolam on neutrophil CD11b & CD 18 expression at clinically used
dose. This effect may have important clinical implications.
S-71 2003; 96; S-1–S-293
S-70
A MURINE MODEL FOR POST-ISCHEMIC INFLAMMATORY were still acidotic (pH 7,12±0,27, n=3) but not hypoxic (pO2
ORGAN DAMAGE AND FUNCTIONAL RECOVERY AFTER 338±93mmHg, n=3) or hypotensive (MAP: 58±10 mmHg, n=11). CPR-
CARDIOPULMONARY RESUSCITATION (CPR) mice displayed significantly increased plasma ALT-levels (17±2 vs
140±64 U/L, bsl vs CA, n=6, p<0.001), whereas sham-operated mice
AUTHORS: A. Menzebach1, M. Lox1, B. Weitkamp2, J. Larmann1, J. showed no increase in transaminases (17±1vs 17±2 U/L, bsl vs 2 days,
Mersmann1, S. Grosse Bockhorn1, H. Van Aken1, K. Singbartl1, G. n=7). Creatinine after CPR was doubled compared to bsl (0.2±0.03 vs
Theilmeier1 0.5±0.08, n=6, p<0,01), while sham-mice remained stable (0.2±0.1 vs
AFFILIATION: 1Dept. of Anaesthesiology & Intensive Care 0.3±0.05 mg/dl, n=7). Sensorimotoric performance scoring (0-8 points)
Medicine, University Hospital Muenster, Muenster, Germany, revealed 7.3±1 points for sham-mice while CPR-animals only reached
2 5.4±1 points (n=9/10, p<0,001). By Western blotting, only in CPR-mice
Atherosclerosis Research Institute, Muenster, Germany. upregulation of VCAM-1 and ICAM-1 in heart, liver and kidney was
INTRODUCTION: Annually up to 750.000 Americans require detected. Neurophils judged by immunohistochemistry were more
cardiopulmonary resuscitation (CPR) after cardiac arrest (CA). About abundant in CPR than in sham liver and hearts.
30% reach the hospital, while only 14% are ultimately discharged. Post- DISCUSSION: Global ischemia causes an early systemic
CPR, patients suffer from a syndrome resembling systemic inflammatory response syndrome with augmented adhesion molecule
inflammatory response syndrome (SIRS) (2). Here, we use a murine expression and consequent neutrophil recruitment, ultimately leading to
model of global ischemia, to elucidate molecular mechanisms causing impaired sensomotoric performance but also renal and liver damage.
post-resuscitation inflammation and organ failure. Taken together we here present evidence for multi-organ failure (MOF)
METHODS: Arterial and venous femoral access was established for due to SIRS after resuscitation in mice. This murine model for post
pressure recordings, blood draws, and drug administration in swiss resuscitation MOF will be very useful to study the role of individual
mice. Cardiac arrest (CA) was electrically induced (50 Hz, 10 V) and proteins in this setting by utilizing gene-deficient mice.
maintained for 5 minutes. Mechanical chest compression commenced REFERENCES:
and epinephrine and bicarbonate were administered. Ventricular 1. Eisenberg MS et al. N.Engl.J.Med. 2001;344:1304-1313.
fibrillation was terminated by defibrillation (1 J). Return of spontaneous 2. Adrie C et al. Circulation 2002;106:562-568.
circulation (ROSC) was documented based on blood pressure. After
weaning and extubation, mice were followed for up to 48h. At sacrifice,
blood from CPR and sham mice was drawn for liver and renal
chemistry. Liver, kidney and brain were harvested for ICAM-1/VCAM-
1 Western blots and leukocyte stainings. Data are presented as
mean±sem. Statistical significance was accepted when non-parametric
testing revealed p<0.05.
RESULTS: CA resulted in loss of perfusion pressure (MAP 65±13 vs
9±1, mmHg, baseline (bsl) vs CA, n=6, p<0,05). Blood gas analyses
drawn with commencing CPR indicated prior hypoxia during CA (pO2
363±143mmHg vs 100±51mmHg, bsl vs CA, n=5/5, p<0,05), acidosis
(pH 7.44±0,07 vs 7.08±0,22, bsl vs CA, n=5/5, p<0,05) and lactate
levels of up to 10 mmol/l. CA had a mortality of 42%. Mice with ROSC
S-71
EFFECTS OF HYPERTONIC-HYPERONCOTIC SOLUTION Tab 1: Relative cell volume and cell viability in response to hypoxia/
ON THE CELL VOLUME AND VIABILITY OF HUMAN reoxygenation and pretreatment with HHS.
UMBILICAL VEIN ENDOTHELIAL CELLS TO HYPOXIA
AND REOXYGENATION control group experimental group
relative cell relative cell
AUTHORS: S. Yuan viability(%) viability(%)
volume(%) volume(%)
AFFILIATION: Department of Anesthesiology, Xiehe Hospital,
baseline 100±14.33 99.7±0.45 100±13.72 99.5±0.73
Tongji Medical Colege, Wuhan, China.
15min 101.3±14.65 99.3±0.36 76.2±9.32*# 99.2±4.89
INTRODUCTION: The beneficial cardiovascular effects of
8hrs 126.4±16.97** 82.7±6.32* 93.6±10.64## 95.3±5.83#
hypertonic-hyperoncotic solution (HHS) resuscitation in the treatment
of hemorrhagic shock are well known. Recent experimental and clinical 24hrs 147.8±24.57** 72.2±5.39** 97.3±16.38## 92.7±5.62##
investigations have suggested that HHS prevents the occurrence of
complications (for example: ARDS, Sepsis, MOF) after shock. vs baseline value, *P<0.05, **P<0.01. vs control group, #P<0.05,
However, the mechanism is poorly defined. The function of the vascular ##P<0.01. n=12
endothelial cell is a key element in the pathogenesis of organ DISCUSSION: These results indicate that hypoxia/reoxygenation
dysfunction after shock. We hypothesized that HHS resuscitation, in result in significantly endothelial cell swelling and decreased viability.
addition to enhancing hemodynamic recovery, protects vascular Pretreatment with hypertonic-hyperoncotic solution should be
endothelial cell. The effects of hypertonic-hyperoncotic on the volume established to prevent hypoxia/reoxygenation-induced cell swelling and
and viability of human umbilical vein endothelial cells to hypoxia and cell death.
reoxygenation were investigated in this article. REFERENCES:
METHODS: To model a clinically relevant hypertonic-hyperoncotic 1. J Biol Chem, 265:20443-20448,1990
environment, human umbilical vein endothelial cells (HUVECs) in 2. Am J Physiology, 268(2 Pt 2):H749-H758,1995
experimental group were preincubated in hypertonic saline and 3. J Trauma, 42(5 Suppl):S38-40,1997
hydroxyethyl starch (HES) added to medium for 15 minutes (final 4. J Surg Res,80(2):210-220,1998
osmolarity: 350mOsm/ml, 2.5mg/ml HES in medium). HUVECs in
control group were preincubated in normal medium for 15 minutes. All
HUVECs in both groups were exposed for 8 hours to hypoxic medium
(95%N2, 5%CO2) and then for 16 hours to normoxic medium (95% air,
5%CO2). HUVECs volume was evaluated by [14C]urea determination
of intracellular water space. Cell viability was analyzed by vital dye
staining.
RESULTS: Cell volume in control group was significantly increased
after hypoxia/reoxygenation, and cell viability was significantly
decreased (P<0.05 or 0.01). Cell in experimental group shrunk after
treatment with HHS for 15 minutes (P<0.05) and then swelled again to
baseline value (P>0.05). Cell viability remained unchanged (P>0.05).
2003; 96; S-1–S-293 S-73
S-72
TRAUMA DEMOGRAPHICS FOR LA COUNTY AND PRIVATE had the smallest penetrating caseload (0.2%). SMM admitted the lowest
HOSPITALS: TRENDS IN TRAUMA ADMISSIONS (2.3%) percentage of blunt trauma compared to all hospitals. USC
admits the highest percentage of blunt trauma as compared to all
AUTHORS: C. Johnson1, R. L. Sapien1, S. J. Rothenberg2, R. Miceli1, hospitals. The 3 county hospitals (HGH, MLK, USC) admit the highest
J. S. Jahr3 percentage of penetrating trauma overall (Figure 1).
AFFILIATION: 1King/Drew Medical Center, Los Angeles, CA, DISCUSSION: Trends in particular injuries may represent areas in
2
National Institute of Public Health, Cuernavaca, Mexico, 3UCLA which prevention efforts and specialized services may be concentrated.
Geffen School of Medicine, Los Angeles, CA. The differences between hospitals are of significant epidemiological
concern. The utilization of trauma centers is dependent on many factors,
INTRODUCTION: Los Angeles County provides trauma services and accurately predicting the future need of trauma centers is an
both through public and private hospitals. Disparities in types of trauma important financial goal. The significantly different rates of blunt and
and demographics between institutions exist. This study describes penetrating trauma between both private and public hospitals in Los
demographics for the 13 accredited level I trauma centers in Los Angeles County demonstrate areas in which efforts could be targeted to
Angeles County based on trauma admission data over a 10-year period certain types of trauma and design of further studies is warranted.
(1992-2001).
METHODS: Trauma data in Los Angeles County from 1992 to 2001 Figure 1: Percentage of Penetrating and Blunt Trauma for each hospital
were separated by hospital, age, gender and type of trauma (penetrating based on the total trauma from 1992-2001
vs. blunt). Data from the following public hospitals: Harbor/UCLA
(HGH), MLK/Drew (MLK), LAC+USC (USC) were compared with
the following private hospitals: Children’s Hospital (CHH), Cedars-
Sinai (CSM), Providence Holy Cross (HCH), Huntington Memorial
Hospital (HMH), Henry Mayo Newhall Memorial Hospital (HMN),
Long Beach Memorial (LBM), Northridge Hospital (NRH), St. Francis
(SFM), St. Mary (SMM), UCLA (UCL). We analyzed the disparities in
trauma admissions for each hospital based on the type of trauma.
RESULTS: In 124,342 trauma admissions over the 10 year period in
LA County, 64.573 or 51.9%, were to the 3 county Trauma Hospitals
(HGH, MLK, and USC). There were 59.769 (48.1%) admitted to the 10
Private Trauma Hospitals (CHH, CSM, HCH, HMH, HMN, LBM,
NRH, SFM, SMM and UCL). There was a significant difference
between hospitals in the number of patients with penetrating and blunt
trauma admitted. Public hospitals admitted a higher percentage of
penetrating injuries as compared to blunt injuries. Penetrating injuries
were 66% of the total injuries reported by public hospitals, whereas
they were 38% for private hospitals. USC and MLK admitted the
highest percentage of blunt and penetrating trauma cases, comprising
25% and 17.2% of the total trauma respectively. One hospital (CHH)
S-73
COMPARISON OF APACHE II AND LODS (LOGISTIC LODS proved to be significantly better calibrated than APACHE II
ORGAN DYSFUNCTION SYSTEM) IN AN INDIAN (C=14.70; H=5.16, p>0.10 for LODS and C=20.94; H=21.24, p<0.01 for
MULTIDISCIPLINARY ICU APACHE II). The calibration curves for the two models are shown in Fig.
1. LODS predicted death more accurately than APACHE II (Mc Nemar‘s
AUTHORS: A. Bagchi, V. K. Arya, P. Chari 2
=6.67, p<0.01).
AFFILIATION: Post Graduate Institute of Medical Education and DISCUSSION: The inverse relation of LOS to mortality and our low post
Research, Chandigarh, India. ICU discharge mortality (2 out of 57 deaths) are at variance with previous
reports1, 2. LODS is simpler and more user friendly than APACHE II, and
INTRODUCTION: APACHE II and LODS have been used to predict avoids some of problems associated with the use of APACHE II3. We
outcomes in intensive care units (ICUs) in many international studies. conclude that of the two models, LODS is better suited to our patient
However, such studies from developing countries like India remain scanty. population.
The aim of this study was to compare these two models in an Indian ICU. REFERENCES:
METHODS: After institutional review board approval, this prospective 1. Annals of Internal Medicine 118: 753-761, 1993.
cohort study was done in our 10-bedded multidisciplinary ICU of a 1000- 2. Critical Care Medicine 26: 1337-45, 1998. 3.Anaesthesia 56: 47-50,
bedded tertiary care center. During the study period (January to December 2001.
2001), 295 patients were admitted to the ICU. Patients with age less than 17
years, ICU stay shorter than 24 hours and those requiring readmission were
excluded from analysis. APACHE II and LODS scores were calculated for
the remaining 203 patients. Discrimination was assessed by comparing the
area under the receiver operating characteristic (ROC) curves, constructing
classification tables and calculating the correct classification rates (CCR).
Calibration was tested using calibration curves and Hosmer-Lemeshow "C’
and "H’ statistics. Discrepancies in the predictions of the two models were
analyzed by cross-tabulating their predictions at a decision criterion of 50%
using McNemar‘s chi-square statistic.
RESULTS: The mean observed in-hospital mortality was 28.1% (n=57;
ICU deaths=55, ward deaths=2). We observed an inverse relationship
between length of stay in ICU (LOS) and mortality. The mean predicted
mortality was 19.7% for APACHE II (Standardized mortality ratio 1.43)
and 28.9% for LODS (standardized mortality ratio 0.97). The mean
APACHE II score for survivors was 11.85 + 5.64 and for non-survivors was
19.93 + 6.94 (p<0.005), while the mean LODS score for survivors was 4.32
+ 2.63 and for non-survivors was 8.13 + 3.58 (p<0.005). Both models
showed similar discrimination (CCRs of the two models at decision criteria
of 20, 50 and 80% were 78.33, 77.83 and 78.38% for APACHE II and
60.59, 80.79 and 77.34% for LODS. The areas under the ROC curve were
0.819 and 0.794 for APACHE II and LODS, respectively). However,
S-75 2003; 96; S-1–S-293
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METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS IN other hospitals. Therefore, in order to reduce MRSA infection and
A GENERAL ICU IN JAPAN: FIVE YEAR SURVEY colonization further in ICU, it would be essential to intensify the
infection control in entire hospital or community. Since the patients who
AUTHORS: S. Oku1, H. Katayama2, K. Morita2 have MRSA were demonstrated to be sicker, we should care these
AFFILIATION: 1Kobe Red Cross Hospital, Kobe, Japan, 2Okayama patients cautiously even if the positive culture is considered to be only
University Hospital, Okayama, Japan. colonization.
INTRODUCTION: Methicillin-resistant Staphylococcus aureus
(MRSA) infection has been spreading among medical facilities, and has
been a serious medical and social problem in Japan. We retrospectively
investigated MRSA infection and colonization in a general intensive
care unit (ICU) in teaching hospital over the five year period.
METHODS: 2516 patients who admitted to general ICU at university
hospital from 1997 to 2001 were examined. To detect MRSA
organisms, specimens from sputa, pharynx or possible infected sites
were obtained from all the patients three times per week, and were sent
to the Central Laboratory. We calculated APACHE II scores of the
patients who admitted in the year of 2001 and compared the scores
between MRSA positive and negative patients. Non paired t-test and
ANOVA with Duncan’s test were used for statistical analysis, and p less
than 0.05 was considered to be statistically significant.
RESULTS: 283 patients (11.2%) were positive for MRSA. Positive
rate gradually decreased year by year (13.6% in 1997, 9.8% in 2001).
Positive rate in emergency-admitted patients (25.5%) was significantly
greater than that in planned-admitted patients (4.9%). Although positive
rates did not change in planned-admitted patients, significant
consecutive reduction of the rates in emergency-admitted patients was
observed (32.6% in 1997, 20.6% in 2001). The majority of MRSA
positive patients were admitted to the ICU either identified as MRSA
positive or cultures taken on admission were positive. Mean of
APACHE II score in MRSA positive patients (17.4 ± 6.2) was
significantly higher than that in MRSA negative patients (12.9 ± 7.9).
DISCUSSION: Recent awareness and measures against MRSA may
affect the consecutive improvement of MRSA infection and
colonization. Significant reduction of positive rate in emergency-
admitted patients would be responsible for this improvement. In most
cases, MRSA was thought to be brought into ICU from the wards or
S-75
PULMONARY INJURY IN PATIENTS UNDERGOING distress syndrome. We have demonstrated that the BAL fluid of patients
COMPLEX SPINE SURGERY undergoing AP fusions has elevated cytokine levels and in some of the
patients this may be the cause of acute lung injury.
AUTHORS: M. K. Urban1, K. Jules-Elysee1, J. Beckman1, K. Sivjee2, REFERENCE:
T. King2, W. Kelsey1 Urban MK et al. Spine. 2001;26:387-390.
AFFILIATION: 1Hospital for Special Surgery, New York, NY, 2New
York Hospital, New York, NY.
INTRODUCTION: After sequential anterior-posterior spinal fusions
(AP) for spinal deformities a significant number of patients demonstrate
pulmonary injury in the form of elevated pulmonary vascular resistance
and hypoxemia. We reported that the bronchoalveolar lavages (BAL) of
these patients revealed increases in neutrophils and lipid laden
macrophages (LLM). This report includes the analysis of the BAL for
cytokine levels: TNF- and IL-6.
METHODS: With IRB approval, 15 adult patients for elective AP
fusions underwent BAL. Following induction of general anesthesia,
BAL was performed prior to surgery (baseline), after insertion of the
posterior spinal instrumentation (PSF), and the morning after surgery
prior to extubation (POD1). The BAL was 3-washes of 60cc of 0.9%
saline from a fiberoptic bronchoscope wedged in the right middle lobe
and lingual. BAL fluid was concentrated via centrifugation and assayed
for IL-6 and TNF- using commercially available ELISA kits.
RESULTS: As a group, patients exhibited increases in BAL cytokine
levels with surgery. Increases in TNF- correlated with increases in IL-6.
There was also a strong correlation with the concentration of IL-6 and
the number of LLM. Patient 8, who had the highest levels of BAL lipid
laden macrophages and acute lung injury, also had high levels of IL-6
and TNF- on POD1. Six patients exhibited significantly elevated TNF-
and IL-6 levels and 3 of the 6 had evidence for acute lung injury.
CONCLUSION: Acute lung injury is a diffuse pulmonary response to
direct injury to lung tissue. There are multiple possibilities for the cause
of direct lung injury during AP spine fusions including the embolization
of fat and bone marrow debris. This probably triggers the release of
acute phase reactants including cytokines. Cytokines are known to
amplify inflammatory responses in the lungs, and an elevated IL-6 level
has been found in the BAL of patients at risk for adult respiratory
2003; 96; S-1–S-293 S-77
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ACCURACY OF LACTATE MEASUREMENT IN BOVINE lactate concentration measured in each native HBOC or blood sample.
BLOOD SAMPLES CONTAINING VARYING "True" or calculated values were then compared to lactate
CONCENTRATIONS OF HEMOGLOBIN-BASED OXYGEN concentrations measured by Model 2300 and 1500 YSI instruments to
CARRIER (HBOC): A TEST OF TWO LACTATE ANALYZERS determine recovery rate. An agreement in method Bland-Altman
analysis compared the calculated with the measured values for each
AUTHORS: J. S. Jahr1, Q. L. Li2, S. J. Rothenberg3, B. Driessen4, R. instrument. Repeatability analysis was not performed.
A. Gunther5 RESULTS: Lactate recovery rate of the YSI 1500 instrument was 100
AFFILIATION: 1David Geffen School of Medicine at UCLA, Los % when compared to calculated lactate values, whereas the YSI 2300
significantly under measured the calculated values (p<0.05), especially
Angeles, CA, 2King/Drew Medical Center, Los Angeles, CA, 3National at higher lactate concentrations (see Figures). Adding HBOC in
Institute of Public Health, Cuernavaca, Mexico, 4University of variable concentrations, ranging from 0.13-5.0g/dL, did not interfere
Pennsylvania School of Veterinary Medicine, Philadelphia, PA, with the linearization coefficients of results measured by the two
5
University of California, Davis School of Medicine, Davis, CA. instruments (r=0.97-0.99).
DISCUSSION: This investigation is a pilot of a larger interference
INTRODUCTION: Lactate level is critical for understanding oxygen study to determine the effect of varying concentrations of HBOC and
delivery to peripheral tissues, especially in hemorrhagic shock and blood in enzymatic-based lactate measurement systems. With only
during resuscitation with HBOCs. In our previous studies in a canine single measurement at each data point, we could not perform the
hypovolemia model, administration of HBOC lead to improvement of traditional second stage of the Bland-Altman analysis, assessing
hemodynamic parameters and decrease in lactate levels. It is not clear if repeatability.
the HBOC preparation itself could interfere with the measurement of In summary, the YSI 2300 significantly under measured the calculated
lactate concentration in the circulation and if variation exists between values the true (i.e. calculated) values especially at higher calculated
different lactate analyzers used in clinical practice when HBOC is lactate concentrations, whereas the YSI 1500, while showing a similar
present. We evaluated two lactate analyzers for their detecting accuracy tendency to underestimate lactate concentrations, showed consistently
by determining recovery rate of lactate in mixed HBOC/ bovine blood less measurement bias than the YSI 2300.
samples that contained various concentrations of lactate. REFERENCES:
METHODS: Samples containing l-lactic acid (5-50 mmol/L, Sigma, Driessen et al. Brit J Anaesth 2001;86(5):683-92.
St. Louis, MO) and HBOC (0.65-13g/dL, Hemoglobin gluatamer-200, Gunther et al. Anesthesiology 2002; 96:A679.
Biopure Corp., Cambridge, MA) in Plasmalyte A (pH=7.4, Baxter,
Deerfield, IL) were prepared. 25-mL of bovine blood was collected in
tubes containing sodium fluoride and potassium oxalate (Becton
Dickinson, Franklin Lakes, NJ) as anticoagulants. 42 samples
containing different final concentrations of HBOC (0.13-5.0g/dL) and
lactic acid (0.62-8.56mmol/L) were generated by mixing bovine blood
with lactic acid and HBOC stock solutions. All samples were measured
in Model 2300 and 1500 (YSI Inc., Yellowsprings, OH) lactic acid
analyzers simultaneously.
"True" lactic acid concentrations were calculated based on the amount
of lactate added to each test sample combined with the background
S-77
LEAD EFFECTS: OXYGEN HEMOGLOBIN DISSOCIATION vivo long-term lead exposure resulting in high levels should be
IN BOVINE BLOOD USING OXYGEN CONTENT FROM evaluated for changes in oxy-hemoglobin dissociation.
TONOMETRY AND A LEXO2CON OXYGEN ANALYZER
REFERENCES:
AUTHORS: J. S. Jahr1, S. Nesargi2, K. Herman3, Z. Tang4, S. J. 1 Bulleova S, Rothenberg SJ, Manalo MA. Lead levels in Blood Bank
Rothenberg5 Blood. Archives of Environmental Health. 2001; 56. 312-313.
AFFILIATION: 1UCLA School of Medicine, Los Angeles, CA, 2King/ 2 Tulasi SJ, Ramana Rao JV. Effects of organic and inorganic lead on
Drew Medical Center, Los Angeles, CA, 3UC Davis School of the oxygen equilibrium curves of the fresh water field crab,
Barytelphusa guerini. Bull Environ Contam Toxicol 1989; 42. 247-53.
Veterinary Medicine, Davis, CA, 4UC Davis School of Medcine, Davis,
3. Kelman, GR. Digital computer subroutine for the conversion of
CA, 5National Institute of Public Health, Cuernavaca, Mexico. oxygen tension into saturation. J Appl Physiol 1966; 21:1375-1376.
INTRODUCTION: Two in a thousand bags of packed red cells
contain toxic lead levels (1). High lead levels interfere with oxygen
loading in blood of fresh water field crab (2). This study evaluated the
effects of varying lead levels on oxy-hemoglobin dissociation using
bovine blood.
METHODS: Remainder sample single healthy donor bovine blood was
obtained and baseline lead level measured. The samples were blended
using two IL tonometers at six oxygen concentrations (2.5, 5, 8, 10, 21,
and 95%) with 5 % CO2 in nitrogen for five minutes after a fifteen
minute wash-in period with each level of oxygen. Three sets of samples
were performed at each oxygen level: 2ml bovine blood with 100 µL
normal saline (control), 2mL bovine blood with toxic lead levels (70µg/
dL) added, 2mL bovine blood with low lead levels (22µg/dL) added.
Samples were anaerobically removed from the tonometer and
immediately evaluated in the LEXO2CON oxygen analyzer for oxygen
content. Oxygen saturations were calculated from the O2 content with
the following formulas: O2 SAT = O2 content - (PaO2 x 0.003)/1.32 x
Hb, where PaO2 = (O2 concentration in supplied tanks) x (PBAR -
PH20), (Hufner factor of bovine blood is 1.32). Oxygen saturation was
plotted against PO2 fitting a fourth order polynominal non-linear
regression to the data, using Kelman's model (3).
RESULTS: Baseline lead level in bovine blood was 1.9 µg/dL. No
clinically significant differences were noted as a function of lead
concentration. See Figure 1.
CONCLUSION: No in vitro effects of low or high levels of lead on the
hemoglobin dissociation curves were observed using bovine blood. In
S-79 2003; 96; S-1–S-293
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ARTERIOVENOUS CARBOXYHEMOGLOBIN DIFFERENCE than those measured with the ABL 725.
IN CRITICAL ILLNESS: FICTION OR FACT? DISCUSSION: Since arteriovenous COHb difference occurred in
health and endotoxemia, this gradient appears not to reflect critical
AUTHORS: M. Westphal, D. Eletr, H. G. Bone, C. Ertmer, H. Van illness. In addition it is noteworthy that measurements performed with
Aken, M. Booke an ABL 625 obviously underestimate COHb concentrations, most likely
AFFILIATION: Department of Anaesthesiology and Intensive Care, due to technical artifacts (1).
University of Muenster, Muenster, Germany. REFERENCES:
1. Biochem Biophys Res Commun 2000; 278: 447-448
INTRODUCTION: It is still debated whether the paradox 2. Biochem Biophys Res Commun 2002; 295: 975-977
arteriovenous carboxihemoglobin (COHb) difference found in critical
illness is a) due to increased COHb production by the pulmonary COHb concentration [%]
enzyme heme oxygenase (HO-1), b) dependent on oxygen tension, or c) ABL 625 ABL 725
caused by technical artifacts using spectrophotometry (1, 2). This study blood gases health endotoxemia health endotoxemia
was designed as a prospective, controlled laboratory experiment to arterial 1.42 ± 0.19 1.46 ± 0.13 3.2 ± 0.09# 3.1 ± 0.14#
determine if arteriovenous COHb difference occurs only in critical mixed venous 0.15 ± 0.01* 0.07 ± 0.01* 1.5 ± 0.08*# 1.48 ± 0.25*#
illness, e.g. endotoxemia, or whether this gradient is also existent in *P < 0.001 arterial vs. mixed venous; #P < 0.001 ABL 625 vs. ABL 725
health.
METHODS: Six adult ewes, weighing 38 ± 3 kg were instrumented for
chronic study. At baseline in the healthy state, cardiopulmonary data
were obtained and blood gases were analyzed for arterial and mixed
venous COHb concentrations. Subsequently, the sheep were subjected
to a continuous infusion of Samonella typhosa endotoxin (10 ng·kg-
1
·min-1) for 24 hours. Then, measurements were repeated. COHb
concentrations were analyzed with both, a standard ABL 625 and an
updated ABL 725. The latter one was accurately calibrated for COHb
wavelengths (SAT 100) to eliminate the FCOHb dependency on oxygen
tension, thereby excluding technical artifacts (1). Using Student’s t-test,
differences in and between groups were calculated. Data are presented
as mean ± SEM.
RESULTS: All endotoxemic sheep exhibited a hypotensive-
hyperdynamic circulation with a decreased systemic vascular resistance
index (767 ± 39 vs. 1277 ± 78 dyne·cm-5·m2; P < 0.001) and an
increased cardiac index (8.4 ± 0.3 vs. 5.8 ± 0.3 L·min-1·m-2; P < 0.001).
In addition, endotoxin infusion was accompanied by pulmonary
hypertension. Arteriovenous COHb difference occurred in both health
and endotoxemia. Interestingly, arterial and mixed venous COHb
concentrations determined with the ABL 625 were significantly lower
S-79
THE USE OF PREHOSPITAL RAPID SEQUENCE DISCUSSION: Our data demonstrates that prehospital RSI is utilized
INTUBATION BY PARAMEDICS FOR AIRWAY twice as frequently for medical emergencies when compared with trauma.
MANAGEMENT IN MEDICAL EMERGENCIES Neurological emergencies were the most frequent indication for RSI
followed by respiratory distress then drug overdoses. Endotracheal
AUTHORS: B. P. McGlinch, R. D. White, D. Hankins intubation is accomplished by the second attempt in most patients. Failed
AFFILIATION: Mayo Clinic, Rochester, MN. intubations indicate the need for paramedic training in alternative airway
devices as well as cricothyroidotomy. RSI by paramedics can be an
INTRODUCTION: Rapid Sequence Intubation (RSI) is a therapeutic effective intervention for airway management in medical emergencies in
intervention utilized by paramedics in many Advanced Life Support the prehospital environment. Studies are needed evaluating patient
(ALS) Emergency Medical Services (EMS) systems for trauma airway outcome after the prehospital RSI intervention to determine its clinical
management but its use in medical emergencies is not widely reported. value.
We report our experience with this intervention in patients with medical
emergencies.
Objective: To assess utilization of, indications for and frequency of use
of RSI by paramedics in medical emergencies.
METHODS: Retrospective, observational review of an RSI database for
utilization of prehospital RSI for medical emergencies. Indications for
RSI: Glasgow Coma Score (GCS) <8, rapidly declining hemodynamic or
respiratory stability, and/or mechanism of injury warranting prompt
airway management (e.g. burns). Patients postictal from seizures were
excluded from the RSI database. Two paramedics were required on-scene
for RSI interventions. Patients were classified as RSI Indicated-
Performed or RSI Indicated Not Performed.
RESULTS: In a 25 month period, 41 trauma and 81 medical patients met
RSI criteria. Etomidate-succinylcholine facilitated RSI was performed in
37/81 (46%) of the medical patients. Neurological conditions (excluding
seizures) were present in 16/37 (42%), respiratory distress in 12/37
(32%), and drug overdoses in 6/37 (16%). In 34/37 (92%) patients
endotracheal intubation was achieved during the first or second attempt.
In 2/37 (5%) patients cricothyroidotomy was indicated due to
unsuccessful intubations and failed Combi-tube placement in the
presence of oxygen desaturation. One patient was transported with bag-
valve-mask ventilation (oxygen saturations >93% en route) after three
unsuccessful intubation attempts. No undetected/unrecognized
esophageal intubations occurred. Proximity to hospital and crew
configuration (presence of only one RSI-trained paramedic on-scene)
were frequent reasons for not performing RSI when clinically indicated.
2003; 96; S-1–S-293 S-81
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CONTINOUS OXYGEN INSUFFLATION (SWINE): AN CONCLUSION: TT-COI is as efficacious as TTJV in maintaining
ADDITIONAL TOOL FOR FAILED INTUBATION oxygen tension for at least fifteen minutes, allowing the clinician time
to secure a more definitive airway.
AUTHORS: C. S. Scher
AFFILIATION: Tulane University Health Sciences Center, New
Orleans, LA.
INTRODUCTION: While Transtracheal Jet Ventilation(TTJV) is an
accepted therapy on the ASA Difficult Airway Algorithim, the
technique requires equipment that is not widely available in clinical
settings. Transtracheal Continuous Oxygen Insufflation (TT-COI) can
performed with any oxygen source, oxygen tubing, one stop cock and
one large bore intravenous needle. We tested the efficacy of TT-COI vs.
TTJV in maintaining adequate oxygen tension and hemodynamic
stability.
METHODS: With Institutional Animal Care and Use Committee
approval, 5 swine weighing 20-30 kg were anesthetized and intubated.
Pancuronium was administered to prevent spontaneous respiration.
Femoral PA and arterial catheters were surgically placed. To facilitate
tracheal cannulation with a 14gauge needle a limited neck dissection
was necessary in this species. Each animal received fifteen minutes
intervals of TTJV and TT-COI. ETCO2, SP02, arterial blood gases,
heart rate, PA and arterial blood pressure was measured.
RESULTS: Both TTJV and TT-COI maintained oxygen tension above
200 mmHg for each 15-minute interval. Significant hypercarbia
occurred with TT-COI but not with TTJV. In TT-COI, elevations of PA
pressure, heart rate and arterial pressure reflected increasing CO2
tension. ETCO2 could not be measured during TT-COI.
TABLE:
TTJV 15 min TT-COI 15 min
Pig pH pCO2 pO2 Pig pH pCO2 pO2
1 7.58 31 232 1 7.04 100 221
2 7.38 52 273 2 7.09 169 245
3 7.42 41 486 3 7.05 106 265
4 7.48 41 479 4 7.05 118 315
5 7.43 58 330 5 7.09 96 274
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EFFECTS OF WEIGHT AND MODE OF VENTILATION ON insufflation did not have significant impact on RI,rs in either group.
RESPIRATORY SYSTEM MECHANICS AND OXYGENATION After pneumoperitoneum RI,rs increased in MO patients with
DURING LAPAROSCOPY "baseline" ventilation in head-down position to 26 cmH2O/L/sec
(P<0.01) and in NW patients "double TV" head-up and head down
AUTHORS: J. Sprung1, L. Tungpalan1, D. G. Whalley2, F. Tommaso3 groups to 19 cmH2O/L/sec (P<0.05). Regardlesof experimental
AFFILIATION: 1Mayo Clinic, Rochester, MN, 2Cleveland Clinic, condition A-aDO2 was always higher in MO patients (139±41 vs.
Naples, FL, 3Cleveland Clinic, Cleveland, OH. 54±20 mmHg in MO and NW group, respectively, P<0.001). The A-
aDO2 was not affected by either the body position, pneumoperitoneum
OBJECTIVE: To test the hypothesis that the increases in either tidal or the mode of ventilation.
volume (TV) or respiratory rate (RR) can improve lung mechanics DISCUSSION: During laparoscopy MO patients have lower static
(static compliance,Cst,rs, and inspiratory resistance,RI,rs) and respiratory system compliance and higher inspiratory resistance
oxygenation in MO patients during laparoscopy. compared to the normal weight patients. Arterial oxygenation during
METHODS: We studied the effects of body weight, position (supine, laparoscopy was affected only by body weight and not by intraoperative
head-up and head-down), and pneumoperitoneum on Cst,rs, RI,rs and body positioning, pneumoperitoneum, or the mode of ventilation.
arterial oxygenation (PaO2) in 6 NW (BMI=21 ±3 kg/m2) and 6 healthy
MO (BMI=48 ±5 kg/m2) patients during laparoscopy. All
measurements were performed at: 1) TV 800 mL and 10 breaths/min
("baseline"); 2) TV 1600 mL ("double TV") and 10 breaths/min; and 3)
TV 800 mL and 20 ("double rate") breaths/min. A Servo Screen 390
V2.0 pulmonary monitor was used to calculate the Cst,rs and RI,rs.
End-tidal CO2 was measured with a mass spectrometer and PaO2 and
PaCO2 with continuous blood gas monitor (Paratrend 7). Using the
alveolar oxygen equation and arterial oxygen tension, the alveolar-
arterial oxygen gradients (A-aDO2) were calculated. Data were
analyzed using repeated measures ANOVA. Statistical significance was
set at P<0.05.
RESULTS: Supine anesthetized MO patients had on average 29%
lower Cst,rs compared to the NW patients (44 vs 62 mL/cmH2O)
(P<0.001). Positioning the patients into the head-up or head-down
before pneumoperitoneum did not affect significantly Cst,rs in neither
MO nor NW groups (P = 0.8). Doubling the TV, but not RR, had trend
to increase Cst,rs in both groups (to 69 and 57 mL/cmH2O in NW and
MO, respectively). Pneumoperitoneum induced large decrease in Cst,rs:
in NW to 34 mL/cmH2 O and in MO to 25 mL/cmH2O, (both P=0.7).
Before pneumoperitoneum RI,rs was higher in the supine MO patients
compared to the NW patients regardless of body position (19 vs. 10
cmH2O/L/sec, P=0.001). Doubling the RR or TV before abdominal
2003; 96; S-1–S-293
S-82
CONTINUOUS RESPIRATORY MANAGEMENT WITH A p=0.062). PEEP (0.6±0.5cmH2O) at T0 in group M was significantly
TRANSPORT VENTILATOR FOR THE PATIENTS AFTER lower than that at TB (2.9±1.0, p<0.01) and than that in group V at T0
CARDIAC SURGERY (4.6±0.7, p<0.01). There was no deterioration of oxygenation and
hemodynamics in either group throughout the time course. Patients in
AUTHORS: T. Nakamura, T. Makita, O. Yoshitomi, T. Maekawa, K. either group had no trouble in the weaning from mechanical ventilation.
Sumikawa The durations of mechanical ventilation and the lengths of stay in ICU
AFFILIATION: Nagasaki University Hospital, Nagasaki, Japan. were similar between group M and V (340±51 min vs 329±34, and
4.2±0.3 days vs 4.5±0.3).
INTRODUCTION: Transport ventilators with a patient-triggered DISCUSSION: Transport ventilator provides more stable respiratory
function have become commercially available. Previous studies have support than manual ventilation during transportation, and they could be
suggested that transport ventilators have performance indexes used safely until the weaning in ICU thanks to the patient-triggered
comparable to the ventilator currently used in ICUs1. The advantages function.
they offer compared with manual ventilation in terms of continuous use REFERENCES:
of them from transportation until the weaning from them in ICU have 1. Chest 118:1109-1115, 2000
not been fully investigated. The present study was carried out to
compare the two types of respiratory management, i.e., the management
with a transport ventilator and that with manual ventilation followed by
a conventional respirator, during the period from transportation until the
weaning from them.
METHODS: With their informed consents, adult patients after cardiac
surgery requiring intrahospital transport postoperatively from operation
room to ICU were randomly assigned to two groups. Group M (n=11)
was managed with manual ventilation during transport followed by a
conventional respirator in ICU. Group V (n=10) was managed with
transport ventilator (LTV 1000: Pulmonetic systems) throughout the
time course. Patients in both groups received 100% oxygen during
transport. Manual ventilation was provided by attending
anesthesiologists via a self-inflating bag at a flow rate of 10 L/min.
Arterial blood gas analysis (pH, PaCO2, PaO2), respiratory rate (RR),
PEEP and tidal volume (VT) were measured at baseline, i.e., 15 min
before transport (TB), on arrival to ICU (T0) and immediately before
extubation (TE). The data were expressed as mean±SD. Statistical
significance (p<0.05) was determined using ANOVA and t-test.
RESULTS: PaCO2 (32±7mmHg) at T0 in group M was significantly
lower than that at TB (41±3, p<0.01) and than that in group V at T0
(41±3, p<0.01). RR and VT (13±4/min and 635±123mL) at T0 in group
M tended to be higher than those at TB (9±1, p=0.056, and 529±110,
Economics; Education &
Patient Safety
Economics; Education &

Patient Safety
S-84 2003; 96; S-1–S-293
S-83
A SYSTEMATIC REVIEW OF THYROMENTAL DISTANCE AS performance of each study at each cut-off by weighting each parameter
A PREDICTOR OF DIFFICULT LARYNGOSCOPY (multiplying the log by the inverse of the variance)1.
RESULTS: 8 studies with a total of 15168 patients were included 2-9.
AUTHORS: K. J. Anderson, J. Kinsella The combined performance (95% Confidence Interval) of TMD at each
AFFILIATION: University of Glasgow Department of Anaesthesia, cut of value is summarized below.
Glasgow, United Kingdom.
TMD cut-off
INTRODUCTION: Thyromental distance (TMD) is one of numerous Sensitivity Specificity PPV LR
predictive tests suggested to screen for difficult laryngoscopy or (cm)
intubation. Its predictive utility been measured in a variety of studies. 0.07 0.99 0.30 9.0
Systematic review with meta-analysis has been used to combine studies 6.0
(0.07-0.08) (0.99-0.99) (0.29-0.30) (0.08-964.9)
increasing their overall precision and reliability. This may allow
0.04 0.98 0.15 3.1
anesthesiologists to quickly assimilate large amounts of information to 6.5
apply to their patient population. The limitations are publication bias (0.03-0.05) (0.98-0.99) (0.13-0.17) (0.00-1476.8)
can limit search for appropriate studies, and heterogeneity of study 0.47 0.89 0.03 3.7
7.0
groups can make meta-analysis misleading if not adjusted for. The (0.45-0.49) (0.88-0.90) (0.02-0.04) (1.4-10.4)
object of this systematic review was to attempt to combine the results of 1.0 0.64 0.01 2.5
all English language studies that measured TMD and prospectively 7.5
(0.99-1.0) (0.61-0.66) (0.00-0.02) (1.4-4.2)
related this to laryngoscopy grading during general anesthesia.
METHODS: A systematic search was performed of Pubmed, Embase DISCUSSION: The sensitivity can be improved by using a greater
and the Cochrane Controlled Trials Register. All prospective English TMD as the cut-off for the test. This reduces the specificity and
language studies that measured of TMD and Cormack and Lehane increases the false positive rate (1-PPV). Likelihood ratios were low
grading (CLG) at laryngoscopy were included. Southeast Asian studies except at 6cm cut-off where the confidence intervals were very wide.
were excluded because sub-analysis revealed that their TMD was The low PPV and LR suggest that TMD alone is a poor predictor of
significantly different to other populations. Studies that included known difficult laryngoscopy. REFERENCES:
cases of difficult intubation, or groups known to be at increased risk of 1. Br J Obstet Gyn 1997; 104: 436-4.
difficult intubation were excluded. All studies were examined in detail 2. British J Anaes 1994;73:149-153.
for acceptable design, and presentation of results. If TMD was 3.Anesth Analg 1996;82:1197-204.
presented in such a way that we could not extract TMD related to CLG, 4.Anest Analg 1995;81:254-8.
we contacted the authors for the original data. Difficult laryngoscopy 5. Anaesthesia 1991;46:1005-1008.
was defined as CLG 3 and 4. Studies commonly used different cut-off 6. Anaesth Int Care 1998;26:382-386.
values (e.g. <7cm) for abnormal TMD, so results were combined for 7. Acta Anaes Scand 2001;45:327-332.
each cut-off. Data was extracted into a standard 2x2 table with 8. Anaesthesia 2001;56:1181-1201.
abnormal/normal TMD on one axis and easy/difficult laryngoscopy on 9. J Anaes Clin Pharm 1998;14:323-8.
the other. From this we calculated the performance (sensitivity,
specificity, positive predictive value (PPV) and likelihood ratio (LR)) of
TMD at each cut off for each study. Meta-analysis combined the
S-84
POPULATION THYROMENTAL DISTANCE CHANGES WITH Median Interquartile
ETHNICITY Ethnicity Data Extracted n
TMD (cm) Range (cm)
AUTHORS: J. Kinsella, S. Gambhir, K. J. Anderson Histogram Data range
Singaporean 211 6.5 5.5 to 7.0
AFFILIATION: University of Glasgow Department of Anaesthesia, 0.5cm intervals
Glasgow, United Kingdom. Histogram Data range
Saudi Arabian 350 7.25 7.25 to 8.25
INTRODUCTION: Many tests including the thyromental distance 0.5cm intervals
(TMD) have been suggested to screen for difficult laryngoscopy or UK TMD to nearest 0.1 cm 244 8.0 7.1 to 8.9
intubation. Their predictive utilities have been subsequently tested in
different populations. For a measurement like TMD there is a range All groups had a significantly different TMD (KWH, p<0.001). Post
within any population, this could conceivably vary in ethnic groups hoc tests confirmed that UK, Saudi and Singaporean patients all had
with different body morphology. To use it as a screening test a cut-off different TMD (MWU, p<0.001 for each comparison).
for an “abnormal” value must be arbitrarily decided. A low value for DISCUSSION: There is a range of TMD within each population. The
one ethnic group may be a normal value for another. Hence, a major reference TMD changes with the ethnicity of the reference population.
problem in applying the results to ones practice is to decide if the The median TMD was greatest for the UK population and smallest for
sample population is representative of your patients. If TMD differs the Singaporean population. Anesthesiologists should take care when
with ethnic origin, this would cast doubt on the ability of a clinician in applying the performance of TMD in predicting difficult laryngoscopy
one country to apply the results of a study from a group of patients of in populations different to their patients. There may be difficulties in
different ethnicity to his patients. The objective of this study was to combining the results by meta-analysis of studies on different
determine if TMD changes with ethnicity. populations. In particular South-East Asian populations have a
METHODS: studies were identified by a literature search of Pubmed, statistically and clinically significantly different TMD from Middle-
Embase and the Cochrane Controlled Trials Register. Authors were eastern or European populations.
contacted for original TMD measurements. Most only recorded whether REFERENCES:
the each patient had TMD less or greater than their cut-off. From 2 1. Anaesth Intens Care 1992;20:139-142.
papers we could extract data from published histograms1-2. These used 2. British J Anaesthesia 1994;73:149-153.
ranges of TMD (e.g. 7-7.5cm), for these we used the mid point of the 3. Anaesthesia 1991;46:1005-1008.
data range (i.e. 7.25cm). One author3 sent us original TMD
measurements to the nearest 0.1 cm. Only study 3 was normally
distributed. Groups were compared by Kruskal-Wallis H test (KWH).
Post hoc comparisons between each pair of groups were performed by
Mann-Whitney U-test (MWU). Results were analysed using Minitab
12.2 for windows.
RESULTS: the descriptive statistics for identified studies are
summarised below.
2003; 96; S-1–S-293 S-86
S-85
A COMPARISON OF LARYNGEAL MASK AIRWAY AND PA significantly more with PAX (53.5%) than with Laryngeal mask airway
XPRESS (26.4%).
CONCLUSION: Our data has shown that correct Laryngeal mask
AUTHORS: M. Maroof1, S. M. Ahmed2, R. M. Khan2, V. Singhal2, K. airway placement not only required significantly fewer attempts and
A. Rizvi2 less overall time, but also demonstrated fewer incidences of trauma and
AFFILIATION: 1University of North Carolina CH, Chapel Hill 27514, post-operative complications as compared to PAX placement. The
NC, 2Department of Anaesthesiology, J.N. Medical College, Aligarh, marked difference in efficiency between them could probably be due to
202002, India. the one size limit of the PAX, or the actual difference in design of the
PAX. However, further studies should be undertaken to compare the
INTRODUCTION: PAXPRESS by VITAL SIGNS Inc 1 is a supraglottic safety and cost-effectiveness of Laryngeal mask airway and PAX once
airway device with presence of gills at the tip and an inflatable different sizes of the PAXPRESS are introduced into the market.
pharyngeal cuff proximal to the distal opening of the airway. They are
convex posteriorly and tapered distally, so as to be accommodated in Comparison attemts tro place and time taken in seconds
the hypopharynx. The current ‘gold standard’ of a supraglottic airway 1st attempt 2nd attempt 3rd attempt TotalTime
device is the Laryngeal mask airway, which forms a seal with the peri-
LMA N=30 27, 90% p<0.01* 3, 10% p>0.05 0 p<0.01* 24.6 SD=3 p<0.01*
glottic tissues. The aim of the present study was to determine the ease
and speed of placement and post-operative laryngo-pharyngeal Pax N=30 20, 67% 4 , 13% 4, 13% 35.4 SD=2.5
morbidity of the PAX compared to the Laryngeal mask airway.
METHODS: 60 adult (ASA I & II) patients of either sex were studied
to compare the ease and speed of placement and post-operative laryngo-
pharyngeal morbidity between the Laryngeal Mask Airway and PAX in
patients undergoing minor peripheral surgery under general anesthesia.
The patients were randomly divided into 2 groups of 30 each
(Laryngeal mask airway, n=30; PAX, n=30). Both the airway devices
were inserted by a single operator who had an experience of more than
50 insertions of each. Laryngeal mask airway sizes 4 & 5 were inserted
in female and male patients respectively. The same size of PAX was
used in both female and male patients because no other size was
available by the manufacturer.
RESULTS: In 90% patients the Laryngeal mask airway was correctly
placed in the first attempt as compared to 66.6% first attempt
placements with PAX (p<0.01). 13.3% patients required 3 attempts and
there were 2(6.7%) failures in the PAX group as compared to none
requiring 3 attempts and no failure in the Laryngeal mask airway group.
The mean total placement time was significantly more in PAX group
(35.4 ± 2.5 seconds) than in Laryngeal mask airway group (24.6 ± 3.1
seconds). The commonest complication was sore throat, which was
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COMPARISON OF THE SUCCESS RATES USING THE patients of the ILMA-FOB group, the ILMA was inserted successfully
INTUBATING LARYNGEAL MASK WITH AND WITHOUT at the second attempt. The time for tracheal intubation was longer for
FIBEROPTIC GUIDANCE. the ILMA FOB group (p<0.001). The incidence of sore throat was 11%
for the ILMA-Blind group, but 0% for the ILMA-FOB group
AUTHORS: H. Bilgin, F. Kaya, D. Köse, S. Tan, G. Korfal, O. Kutlay (p<0.001).
AFFILIATION: Uludag Univercity Medical School, Bursa, Turkey. DISCUSSION: As a conclusion, the time for intubation using the
ILMA with fiberoptic guidance was longer. However, using fiberoptic
INTRODUCTION: The intubating laryngeal mask (ILMA) allows guidance during intubation with ILMA has advantages of increasing
blind intubation of the trachea in patients with/without difficult airways, success rates and performing intubation without sore throat.
which has a success rate of 82-99.3% (1, 2). The aim of this prospective REFERENCES:
randomized study was to compare of the success rates for intubation 1. Br J Anaesth 75: 228-9, 1995.
using the ILMA blind or fiberoptic guidance. 2. Br J Anaesth 79: 704-9, 1997.
METHODS: After Ethic Committee approval, 80 patients scheduled
for servical spine pathologies, aged 18-78 years, and ASA I-II were
included. After preoxygenation and induction of anesthesia with
propofol 2.5mgkg-1 and fentanyl 1 gkg-1, the ILMA was inserted.
Following successful ILMA insertion, vecuronium 0.1 mgkg-1 was
given. After 2 minutes, patients were intubated using ILMA with either
fiberoptic guidance (ILMA-FOB, n=40) or blindly (ILMA-Blind,
n=40). The ILMA insertion time was defined as the time from removal
of the face mask to the time ventilation was established through the
airway with CO2 confirmation. Tracheal intubation time was defined as
the time from loss of CO2 due to disconnection of the circuit for tracheal
intubation to the time of reapperance of the CO2 from the tracheal tube
with no evidence of cuff leak with positive pressure ventilation. Times
for successful airway insertion and tracheal intubation, the number of
attempts for successful airway insertion and tracheal intubation, the
incidence of sore throat in both groups were recorded. Statistical
analysis was performed using Fisher’s exact test. p<0.05 was
considered statistically significant.
RESULTS: Success rates of the first attempt and overall for the ILMA
insertion were 90%-95% for the ILMA-Blind group, and also 90%-
100% for the ILMA-FOB group. First attempt and overall success rates
for tracheal intubation were 80%-95% for the ILMA-Blind group, and
also 100%-100% for the ILMA-FOB group. In four patients of the
ILMA-Blind group, successful ventilation were performed at the third
attempt. In two of these patients, tracheal intubation had failed. In four
S-88 2003; 96; S-1–S-293
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THE INCIDENCE & ETIOLOGY OF REINTUBATION anesthesiologists participated in their care; ASA physical status 1 & 2
DURING THE FIRST 24 HOURS FOLLOWING SURGERY AND was 40%; ASA 3 & 4 was 60%. The total ICU admission in the control
ANESTHESIA: A TWO YEAR RETROSPECTIVE ANALYSIS group was 10%.
AUTHORS: I. A. Hilmi1, R. Abdullah1, R. Nicolau-Raducu1, A. Table 1: Study Group Data

Soaita2, E. Sullivan1, J. Quinlan1 Category Count
1 and 2 22
AFFILIATION: 1University of Pittsburgh, Pittsburgh, PA, 2Graduate ASA
3 and 4 71 76 %
School of Public Health, Pittsburgh, PA. Elective 86
Surgery
INTRODUCTION: Laryngoscopy and endotracheal intubation causes Emergency 7 8%
< 60 years 29
a marked sympathetic response with the potential to elicit deleterious Age
> 61 years 64 69 %
side effects in some patients (1). In addition to undesired sympathetic Senior 68
stimulation, premature extubation lead to other serious complications MD
Junior 25 27 %
(2). Urgent reintubation during the first 24 hours following anesthesia Reintubation Floor 9
not only predisposes patients to all of the serious complications OR 45 49 %
Location of
associated with airway management, but may increase hospital cost due PACU 38 41 %
to prolonged PACU stay and possible ICU admission. Patient
ICU Admission 38
METHODS: A retrospective 2-year case analysis was performed on
Respiratory 74
patients who received an anesthetic and were reintubated during the Reason for
Cardiac 10 11 %
first 24 hours postoperatively. For our control group we randomly Reintubation Miscellaneous 9 10 %
selected 400 patients who were successfully extubated. The following
data were collected and analyzed: age, weight, ASA physical status, DISCUSSION: The reported incidence of reintubation in ICU patients
type of surgery, type of anesthesia, intraoperative medications, is 20 % (3). There is no published data for the incidence of reintubation
transfusion therapy, location and timing of re-intubation. We reviewed immediately following surgery and anesthesia. In our study, the
the documented reason for reintubation, duration of PACU stay, ICU incidence of urgent reintubation following anesthesia is 0.2 %. The
admission, and the seniority of the anesthesiologists. Data was analyzed characteristics of the study group are advanced age, weight > 101 kg,
using the Chi-Square and Kruskal-Wallis tests. P value of 0.05 was ASA physical status > 2, and elective abdominal and thoracic surgery.
significant. The average PACU stay for the study group was 5 hours, almost twice
RESULTS: Our hospital performs more than 25, 000 surgical the average PACU stay for the control group. The study group also had
procedures/year. During 2 years, 93 patients (0.2 %) were urgently a much higher incidence of ICU admission. It is surprising that most of
reintubated 24 hours postoperatively. There were equal numbers of the patients who required reintubation had a senior anesthesiologist (> 5
males and females in both groups. The median age in the study and years experience) involved in their care.
control groups was 68 years and 58 years respectively (p< 0.001). In the REFERENCES:
study group the procedures were abdominal 39 (42 %), thoracic 21 (22 1. Can. J. Anesth, 36 (4), 367-9, 1989.
%), neurosurgical 15 (16 %), vascular 9 (10 %), orthopedic 9 (10 %) 2. BJA, 71, 561, 1993.
and other 9 (10 %) (Table 1). In the control group 22% were abdominal 3. Respiratory Care, 47 (4), 483-95, 2002.
cases and 12% thoracic (p < 0.001); 42 junior and 52 senior
S-88
QUALITY OF STUDY PROTOCOLS AND DATA ANALYSES IN order. The mean quality scores were 47%, 38%, 46%, and 43% (Table).
RANDOMIZED CONTROLLED TRIALS AMONG GENERAL Among the four journals higher scores were assigned for control
ANESTHESIOLOGY JOURNALS appearance (80%, 69%, 85%, and 73%) and discussions of side effects
(74%, 61% 68%, 65%). However, scores were very low for
AUTHORS: M. V. Greenfield, A. L. Rosenberg, M. D. Nauss, A. randomization blinding (6%, 7%, 3%, and 4%), blinding observers to
Shanks, M. Sliwinski, M. O'Reilly results (2%, 0%, 2%, 0%), post-beta estimates (12% 33%, 16%, 3%),
AFFILIATION: The University of Michigan, Ann Arbor, MI. and discussion of withdrawals (4%, 0%, 9%, 6%).
DISCUSSION: Among four major general anesthesiology journals in
INTRODUCTION: Medical treatments and procedures require the year 2000, on average, none achieved even a 50% quality score for
validation before they are determined to be of benefit to patients. Recent their randomized clinical trials. Our results suggest that investigators
emphasis (1,2) on the quality of clinical trials in the medical literature need to improve the rigor of study protocols and data analysis.
reflects the ongoing concern among clinicians. We studied all Moreover, peer reviewers can advance the quality of randomized
randomized clinical trials in four general anesthesiology journals in the clinical trials by more critically appraising the process of
year 2000 to identify specific areas for improvement in the conduct, randomization, power analysis and sample size estimation, and how
implementation, analysis, and reporting of clinical trials. observers are blinded to results of ongoing studies.
METHODS: All Randomized Clinical Trials (RCTs) published REFERENCES:
between January 2000 and December 2000 in four anesthesiology 1. Anesthesiology 95: 1068-73, 2001.
journals (Anesthesiology, Anesthesia & Analgesia, Anaesthesia, 2. Anesthesiology 95: 1051-3, 2001.
Canadian Journal of Anaesthesia) were retrieved with a MEDLINE 3. Control Clin Trials 2(1): 31-49, 1981.
search. Articles were limited to (1) publication date between January 4. JAMA 272(2): 108-13, 1994.
and December 2000, (2) human trial, and (3) a publication type of
randomized controlled trial. Three hundred thirty-nine articles met our
study search criteria. We excluded 59 papers that were studies of
pharmacokinetics, cadavers, or healthy volunteers. The study articles
were photocopied with all identifiers removed; the reviewers (MG and
AR) were blinded to the journal and authors. We used the modified
Chalmers quality assessment tool to determine a quality score for each
article (3,4). Assessment included rating the appearance of control
treatment, blinding of randomization process, blinding of patients and
observers, sample size estimation and power analysis, compliance
measures, results of randomization on pretreatment variables, major end
points, post-beta estimates, confidence intervals, statistical analyses,
withdrawals, and side effects discussions. Points were assigned by
consensus. Scores were weighted using the following formula: points
achieved/total possible points) times 100.
RESULTS: Data are presented for Journal 1, Journal 2, Journal 3, and
Journal 4, respectively. The journals are listed in a blinded, random
2003; 96; S-1–S-293 S-90
S-89
VARIABILITY OF EXCLUSION CRITERIA USED IN MUSCLE used in similar study types. This may be explained by the fact that
RELAXANT RANDOMIZED CONTROLLED TRIALS certain studies may have actually used some of the exclusion criteria
without listing them as criteria for their study.
AUTHORS: A. Kovac, K. Jacobs, C. Weber, C. Elliott None of the studies reported the proportion of patients excluded from
AFFILIATION: University of Kansas Medical Center, Kansas City, their studies, making it impossible to determine actual exclusion
KS. numbers.
Conclusions There was significant variability among the use of
BACKGROUND: A goal of anesthesia research is to validate or refute exclusion criteria for similar types of muscle relaxant RCTs which
existing knowledge or generate new information regarding drugs or could lead to different study populations and ultimately produce
techniques to improve patient outcomes. Many randomized controlled different results. Use of standard methodology and set of exclusion
trials (RCT) may restrict their sampling population excluding certain criteria is necessary in similar studies to eliminate this variability.
types of subjects (1). Literature review has found variability in the REFERENCES:
exclusion criteria identified in similar RCTs (2-4). Furthermore, the (1) Brit Med J 1984;289:1218-1284
exclusion criteria may not be well defined or justified. The purpose of (2) Amer J Med 1999;107:59-64
this study was to compare exclusion criteria cited in anesthesia masters (3) J Health Services Research and Policy 1999;4:112-121
theses involving muscle relaxant RCTs conducted at our hospital. (4) Lancet 1990;335:827-838.
METHODS: This retrospective study was IRB exempt and reviewed
exclusion criteria of 16 masters theses which involved muscle relaxant
RCTs conducted from 1987 to 2000.
RESULTS: In 16 RCTs, a total of 21 unique exclusion criteria were
used. The mean (+/-SD) number of exclusion criteria used for each
study was 6.0 +/-1.63 (range 4-6). The most frequently cited exclusion
criteria was neuromuscular or nervous system disease (15/16,94%),
followed by drug interactions (75%), ASA class (75%), pregancy
(68%), liver/renal disease (56%), obesity (37%), type of intubation
(37%), drug allergy (25%), age limits (19%), and length/type of surgery
(6%). Ten exclusion criteria were each used in only one (6.25%) of the
16 studies. These included increased intraocular pressure, surgery time
less than 90 min, age>65 years, age>75 years, drug abuse, facial
surgery, hiatal hernia, premedication, protruding incisors, and tobacco
use.
DISCUSSION: All but one study used the presence of neuromuscular
disease or nervous system disorder as an exclusion criteria as these
disorders can affect the duration of neuromuscular block which would
alter results. Of the 21 listed unique exclusion criteria, 13 were cited in
25% or fewer studies and 10 were used in only one study. This reveals
that there is a great amount of variability between the exclusion criteria
S-90
THE EFFECTS OF RANITIDINE, OMEPRAZOLE AND difference in the number of acid refluxes / hr. between ranitidine and
PLACEBO ON INTRA OPERATIVE GASTRO-OESOPHAGEAL and omeprazole. The "mean pH < 4" was significantly different when
REFLUX IN PATIENTS WITH SYMPTOMS OF REFLUX comparing placebo to omeprazole and just outside the level of
significance comparing placebo to ranitidine. Again there was no
AUTHORS: S. C. Minogue, T. Corcoran, R. Fanning, G. Shorten significant difference between "mean pH <4" for omeprazole compared
AFFILIATION: Dept. of Anaesthesia and Intensive care medicine, to ranitidine.
Cork University Hospital, Cork, Ireland. CONCLUSIONS: The most important finding of our study is that the
preoperative administration of ranitidine and omeprazole decreases the
INTRODUCTION: Pulmonary aspiration is a rare but devestating incidence and duration of acid regurgitation in patients undergoing
complication of general anaesthesia.The mortality associated with this general anaesthetics and that there is no difference in the incidence of
event has been reported as being over 60% for severe cases1. Due to an regurgitation in the group recieving omeprazole as a premedication
awareness of the problem and changes in clinical practice intended to compared to the group receiving ranitidine.These data support the
prevent it, the incidence has decreased dramatically.One factor likely to routine preoperative administration of these agents to patients with
contribute to the incidence of aspiration is the presence of Gastro- symptoms suggestive of GERD.
esophageal reflux disorder.Five to ten percent of the adult population REFERENCES:
suffer from GERD2.The presence of "heartburn" and acid regurgitation 1. Arch Surg 1973; 106: 49-52
is predictive of GERD and thus puts the patient at increased risk for 2. Scand. J Gastroent. Supp. 1995; 211: 5-6
perioperative reflux of gastric content3.Agents which alter the volume 3. Lancet 1990; 335: 205-9
and acidity of gastric contents may decrease the likelihood of adverse
outcome associated with this condition.The aim of this study is to
compare the effects of ranitidine and omeprazole on intra-operative
reflux in patients symptomatic for GERD undergoing elective surgery.
METHODS: With IRB approval and informed patient consent,thirty
ASA I and II adult patients describing specific symptoms of GERD and
undergoing elective surgery were enrolled and then randomly allocated
to recieve placebo, ranitidine or omeprazole as a premedicant.
Following administration of a standard general anaesthetic, a pH probe
was introduced into the esophagus, esophageal pH monitored and
episodes of reflux (defined by an abrupt decrease in the pH to a value of
<4 ) measured and recorded using a Synectics digitrapper.Statistical
analysis was performed using unpaired one tail t- tests and Chi squared
tests as appropriate.P< 0.05 was taken to indicate significance.
RESULTS: The groups were simliar in terms of age, weight, height
and Body Mass Index.as was the symptom score between the two
groups. The number of acid refluxes / hour in the placebo group was
significantly greater then in the ranitidine group and just outside the
level of significance when compared to omeprazole.There was no
S-92 2003; 96; S-1–S-293
S-91
EVOLUTION OF ANESTHESIA MANAGEMENT FOR GROUP A GROUP B DIFFERENCE
BARIATRIC SURGERY Mean± SEM Mean± SEM Mean± SEM
AUTHORS: J. Krombach, S. Perretta, F. Pelligrini, E. Lobo, M. Patti, ANESTHESIA 343 min 277 min 66 ± 21
C. U. Niemann TIME ±17.11 N=16 ±11.09 N=16 p= 0.0032
AFFILIATION: University of California San Francisco, San 4.8 L 3.5 L 1.3 ± 4
CRYSTALLOIDS
Francisco, CA. ±3.87 N=16 ±1.6 N=16 p=0.0045
INTRODUCTION: Morbid obesity has become a significant public 416 ml 256 ml 160 ± 70
EBL
health problem in the USA. Patients do not frequently respond to diet ±58 N=16 ±39 N=16 p=0.029
and exercise as a means of weight loss. Surgical treatment by gastric GENERAL-
bypass surgery is increasingly used as an alternative. We report the GENERAL DIFFERENCE
EPIDURAL
result of a study examining the evolution of the surgical and anesthetic ANESTHESIA Mean± SEM
ANESTHESIA
approach in this patient population.
METHODS: We reviewed the charts of 32 patients undergoing gastric INTRAOPERATIV 598 µg 294 µg 304 ± 95
bypass at our institution. Group A (n=16) represents patients (BMI E OPIOIDS ± 103 N=13 ± 35 N=19 p= 0.0033
49±10) who had open gastric bypass surgery in 1998 (when the program DISCUSSION: We conclude that with experience in this procedure,
was initiated at our institution) until early 2000, while Group B (n=16) operative time, blood loss and fluid resuscitation are decreased. More
consists of patients (BMI 50±9) who had the same procedure more than important, we strongly advocate a combined general -epidural
one year later. anesthesia which results in significant reduction of intraoperative opioid
RESULTS: We noticed significant changes in the length of anesthesia use and may facilitate extubation and reduce the risk of respiratory
time, intraoperative crystalloid administration, and a decrease in blood depression and sleep apnea.
loss with increased experience (table1). In addition, we examined the
use of intraoperative opioid use in all patients receiving general
anesthesia versus combined general-epidural anesthesia (thoracic).
Perhaps the most important observation was a significant decrease in
intravenous intraoperative opioid usage, in patients receiving a
combined epidural and general anesthetic.
Table1:
S-92
THE PULMONARY CHANGES IN LAPAROSCOPIC RADICAL pulmonary variables (p0.38, p<0.04 for all pairwise differences).
PROSTATECTOMY USING INTRAOPERATIVE Reduction of tidal volume did not correlate with BMI.
SPIROMETRY
Mean (SD) of the pulmonary values at three different statuses
AUTHORS: M. W. Lew, A. Falabella, J. J. Ge Trendelenburg/
AFFILIATION: City of Hope National Medical Center, Duarte, CA. Variable Supine Trendelenburg
Pneumopitoneum
INTRODUCTION: Complex procedures, such as radical Peak Pressure
20.6(4.2) 24.4(4.7) 33.8(5.8)
prostatectomies are being done laparoscopically. There has been no data (mmHg)
regarding the effects of this surgical procedure on a patient’s pulmonary Plateau Pressure
physiology. The closest data has been on patient’s undergoing 17.2(4.2) 20.8(5.2) 32.1(5.9)
(mmHg)
laparoscopic cholecystectomies.1 Because of the unique considerations
in a laparoscopic prostatectomy, we seek to determine the statistical Tidal Volume
942.7(129.9) 866.3(124.7) 773.0(129.4)
significance of positioning and pneumoperitoneum on the pulmonary (ml)
function. Compliance
METHODS: After the approval of the City of Hope National Medical 68.8(14.1) 49.7(11.9) 26.2(5.8)
(cm H2O)
Center IRB, thirty consecutive laparoscopic prostatectomy charts were
retrospectively reviewed. The D-lite flow sensor (Datex-Ohmeda) was Resistance
12.2(2.8) 15.2(5.0) 19.2(9.0)
applied in all of our cases. The mean age of the patients was 65.5 years (cm H20/1/s)
of age with an average ASA Class of III and a mean body mass index DISCUSSION: The steep Trendelenburg position and the
(BMI) of 27.4. After induction of general anesthesia, the ventilator was pneumoperitoneum produce significant decreases in dynamic
set to a tidal volume of 10 ml/kg, a rate of 8, and an I:E of 1:2.5. The pulmonary compliance and tidal volume while increasing both peak and
peak pressure, plateau pressure, tidal volume, dynamic compliance, and plateau pressure and airway resistance. BMI appears to have a role on
airway resistance were measured in the supine position, the the changes in pressures and resistance. Though we have not seen a
Trendelenburg position (35 degrees), and the Trendelenburg/ change in morbidity or mortality, this procedure places compromised
pneumoperitoneum position (intraabdominal position of 15mmHg). The patients at an increase anesthetic risk, especially for obese patients.
differences in the pulmonary values were compared among the supine REFERENCE:
position, the Trendelenburg position and the Trendelenburg/ 1
pneumoperitoneum position. Means were compared using paired t-test. Anaesthesia 50:286, 1995.
The influence of BMI on the change in pulmonary values were assessed
by Pearson correlation analysis.
RESULTS: The Trendelenburg position caused a significant increase
in the peak pressure, plateau pressure, and airway resistance
(p<0.0001); a significant decrease in the compliance and tidal volume
(p<0.002) compared to supine position. The initiation of the
pneumoperitoneum significantly exacerbated the change in all of the
2003; 96; S-1–S-293 S-94
S-93
POSTOPERATIVE COGNITIVE DYSFUNCTION (POCD) AND RESULTS: A total of 286 pts (48.5 F; 51.5 M; median age 58 yrs old)
DELIRIUM IN A SHORT TIME SURVEY had at least a single episode of POCD. Delirium presented in 46 pts
(1.8%) no sex differences; 8 pts received general anaesthesia for more
AUTHORS: D. Cattano1, A. Paolicchi1, G. Licitra1, E. Panicucci2, E. than 3 hrs and 35 underwent inhalational anaesthesia (P< 0.002); 83.2%
Pelati1, F. Giunta1 were premedicated and 62.2% used to be antagonized for muscle
AFFILIATION: 1Dept of Surgery University of Pisa S.Chiara relaxants. Differences were significative at awakeness for length group
Hospital, Pisa, Italy, 2Dept of Human and Enviromental Sciences (P< 0.001) and at 36-48 hrs interval for age group (P= 0.006). No
University of Pisa, Pisa, Italy. complications were reported.
DISCUSSION: Postoperative cognitive dysfunction occurred at
INTRODUCTION: Postoperative cognitive dysfunction POCD is awakeness from general anaesthesia with an incidence higher in at risk
recognized occurring after general anaesthesia and mostly in elderly group patients (surgery length 180 minutes). Delirium seems to appear
patients [1]. Usually it is a benign and transient condition but long-term later and related to age factors. General anaesthesia seems to predispose
effects could arise [2]. Delirium could present as a postoperative to develop POCD and Delirium. Postoperative cognitive deficit is
cognitive impairment, especially in elderly patients, and it is associated frequent, it is usually benign and transient, but a clear definition and a
with a substantial morbidity and mortality rate ranging 20-50% [3]. time limit diagnosis has not yet been defined.
Delirium is characterized by acute and fluctuating impairment of REFERENCES:
cognition i.e. altered consciousness and attention as memory, language, [1] Br J Anaesth 1998; 81: 449-462;
perception and thinking, associated commonly to agitated behaviour, [2] Lancet 1998; 351: 857-861;
disturbed psychomotor activity and sleep-wake cycle [4]. Delirium [3] Anesth Analg 1995; 80: 1223-1232;
often occurs in hospitalized patients (10-20%), particularly in [4] NEJM 1999; 340 (9): 669-676;
postsurgical (10-15%) and in ICU (30%) admitted patients [5] JAMA 2002, 286: 2703-2710;
[4,5,6].Within a broader project of research on aging process and [6] Intensive Care Med 2001; 27: 1297-1304.
vulnerability of the old patient, the aim of the present study was to
evaluate during a short period of observation of 60 postsurgical hours
the incidence rate of postoperative cognitive dysfunction (POCD) and
of Delirium, and to assess possible risk factors in a surgical adult
population.
METHODS: Retrospective study on 2547 (1231 M, 1316 F) ASA I-III
of 6600 consecutive patients undergoing abdominal, vascular, urologic
and trauma surgery in general anaesthesia with no dementia or
psychosis history. Each patient was evaluated every 6 hours with a
specific registration form. The model analysed four parameters to
recognize every impairment of cognition (confusion, disturbed
psychomotor activity, altered mood, sedation), every alteration of sleep-
wake cycle and well-being factors as pain relief (good pain control). All
these parameters were clinically assessed by a physician. Statistical
analysis was performed using Chi-Squared test.
S-94
THE EFFECT OF THE ADDITIONAL (PGY-4) YEAR ON
SUBSPECIALTY EDUCATION: A TEN YEAR REVIEW
AUTHORS: J. E. Havidich1, G. Haynes1, C. K. Lineberger2, J. G.
Reves1
AFFILIATION: 1Medical University of South Carolina, Charleston,
SC, 2Duke University, Durham, NC.
The purpose of this study is to determine the long-term effect of
requiring an additional year of anesthesia residency (PGY-4) instituted
in 1989 by the American Board of Anesthesiology (ABA) on the
number of individuals who pursued twelve-month subspecialty
anesthesia training. We tested the hypothesis that extending education
by a year would decrease the number of trainees.
METHODS: Surveys were collected from approved Anesthesia
Residency Training programs in the United States from 1989-2001. The
questionnaires were designed to determine the number of individuals .DISCUSSION: In 1988-89, the ABA required a PGY-4 year for entry
pursuing subspecialty training during the PGY-4 and PGY-5 years. The into the examination and certification process. Prior to this time, the
time periods were divided into three categories: 6 months, 6 to 12 PGY-4 year was an elective year in which individuals could pursue
months, and 12 months of subspecialty training. The subspecialties are subspecialty training. At the time this policy was instituted, there was
cardiac anesthesia, pediatric anesthesia, pain management, obstetrical concern this mandate would result in a decrease in the number of
anesthesia, outpatient anesthesia, intensive care medicine, and research. anesthesia subspecialists1. Our data illustrates an increase in the number
We report only twelve-month data. of individuals pursuing twelve month subspecialty training. The
RESULTS: The number of anesthesia residents (PGY-5) pursuing 12 increase of residents in fellowship training occurred at a time when the
month subspecialty training has increased over the last decade despite a total number of anesthesia residents in training decreased. Our data also
noted decrease in residents (PGY-2). (See graph). However, the specific indicates major changes in the subspecialty pursued during the last
subspecialty distribution of fellows has changed. Pain Management decade. Pain management comprises nearly one half of all individuals
increased the most from 11% during 1989-90 to 45% in 2001. The pursuing 12 month subspecialty training during the PGY-4 and PGY-5
greatest decline in the number of fellows has occurred in Critical Care years. We conclude that factors other than the duration of training
medicine. In addition, the number of individuals pursuing specialty influence the selection of subspecialty education.
training during the PGY-4 year has declined REFERENCES:
1
Reves JG, Newfield P. Stricker TW, Sladen RN, Edgar RD. The effect
of the extended (3-year) anesthesia curriculum on subspecialty
education. J Cardiothorac Vasc Anesth. 1992 Aug;6(4): 392-8.
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S-95
A SIMPLE METHOD FOR ASSESSING KNOWLEDGE year progressed (F Statistic = 7.25, df = 19, p = 0.014) but this effect
GROWTH DURING SUBSPECIALTY ANESTHESIA was minor compared to the neuroanesthesia learning that occurred
TRAINING during each rotation. Residents felt more positively about the testing
after the rotation: 67% (pretest) vs 88% (posttest) felt that the tests
AUTHORS: C. R. Turner, M. V. Greenfield, A. L. Rosenberg would help their Anesthesiology In-training Examination scores. 94%
AFFILIATION: University of Michigan, Ann Arbor, MI. of the residents felt they tested better after the rotation. Most residents
liked testing online (78% pre, 88% post).
INTRODUCTION: Residency training often lacks objective DISCUSSION: We have presented an evaluation of a simple tool for
evaluation of learning within the educational program. Accurate assessing the acquisition of factual knowledge during an anesthesia
outcome measurements are needed so that changes to the educational subspecialty rotation. This tool will allow us to modify subspecialty
process can be evaluated and followed over time. Furthermore, the teaching to investigate the effects of altered educational techniques on
ACGME has recently introduced a requirement for an objective the learning of didactic knowledge within these rotations. Most of the
assessment of learning during anesthesia subspecialty rotations without anesthesia residents using this tool felt that the testing was a useful
specifying how that should occur (1). Our objective was to demonstrate experience.
an outcome assessment tool using written pre- and post-rotation REFERENCES:
examinations to judge the acquisition of knowledge by anesthesia 1.http://www.acgme.org/req/040pr101.asp.
residents during a neuroanesthesia rotation.
METHODS: Questions were chosen specifically based on the
published objectives of the rotation and were written by our
neuroanesthesia faculty or obtained from outside sources. Questions
were often rewritten extensively to clarify, update, or target the
questions to specific areas and were paired, e.g., a question on brain
death on the pretest would be matched to a question of similar
complexity regarding brain death on the posttest. Questions were
administered on a web-based testing system (UM Lessons©). Test
integrity was assured by allowing only defined residents access to the
tests and verifying their identities using high-level (Kerberos)
passwords. Residents took the tests within a few days of beginning or
ending their neuroanesthesia rotation. Residents also completed
subjective questionnaires evaluating the experiences.
RESULTS: Pretest and posttest scores for each resident as a function of
the month of their Neuroanesthesia rotation (Academic Year 2001-
2002) are shown in the figure. Mean pretest score was 48% and mean
posttest score was 71% for the group. The mean difference in pretest
and posttest scores was significantly different (Student‘s T-test, T-
statistic = 12.44, df 20, p<0.0001). There was a statistically significant
increase in pre-rotation neuroanesthesia knowledge as the academic
S-96
THE LEARNING STYLES OF ANESTHESIOLOGISTS Table 1. SEA Learning Style Group Results
AUTHORS: I. T. Cohen Group Responder Active Reflect Sensory Intuit. Visual Verbal Sequen. Global
(n) Type
AFFILIATION: Children's National Medical Center, Washington, DC. SEA Anesthesia 41% 59%a 64% 36% 79% 21% 48% 52%b
(56) Educators
INTRODUCTION: Do anesthesiologists, as a group, have a learning UMI2 Engineering 67% 33% 57% 43% 69% 31% 71% 29%
style profile? Learning styles and strategies are the strengths and (858) Students
preferences that form our educational experience. Numerous UMD3 Adult Ed. 50% 50% 60% 40% 73% 27% 51% 49%
investigators including Myers-Briggs, Koch, Strenberg and Felder have (369) Tech mangs.
examined these characteristics. Myers and Briggs observed that their a
indicators often correlated with academic and professional pursuits. In - SEA vs. UMI: p < 0.0001 b - SEA vs. UMI: p = 0.0003
this study, the learning styles and strategies of anesthesiologists were DISCUSSION: The anesthesiologist’s percentages are similar to those
assessed to determine if any trends exist in our medical specialty. obtained at University of Michigan, School of Engineering, for Sensory
Method: At the 2002 Spring Meeting of the Society for Education in vs. Intuitive and Visual vs. Verbal. This is consistent with previous
Anesthesia, attendees were surveyed using the Index of Learning Style studies of math-science students.4 In contrast to the engineering
Questionnaire1. The questionnaire, initially designed to assess students, our results show a significant greater percentage scored as
engineering students, consists of forty-four questions and scores the "Reflective" learners and an split evenly in the Sequential - Global
respondent in four dichotomous areas: Active vs. Reflective, Sensory category. Reflective learners prefer individualized learning
vs. Intuitive, Visual vs. Verbal, and Sequential vs. Global. Individual environments. This is consistent with the anesthesiology experience and
scores range along a continuum (0 to 11) for each area. A score of 4-7 its focus on one-on-one patient care and teaching, as opposed to clinics
signifies an essentially balanced condition, 2-3 and 8-9 reflects a and serial group rounds. The more balanced picture in the last category
moderate preference towards one pole, 0-1 and 10-11 reflects a strong may be the norm, with high Sequence scores being particular to
preference towards one pole. The results were assessed using engineers.
descriptive statistics and chi square analysis. REFERENCES:
RESULTS: Of the 139 registered attendees, 59 (42.4%) returned the 1. Felder R.M. and Soloman B.A.. Index of Learning Styles
questionnaire. Three questionnaires were incomplete and were not Questionnaire. 1999.
included in the group data. A review of the scores showed a strong 2. Montgomery S. Proc. 25 th ASEE/IEEE Frontiers in Education
polarization towards Reflective and Visual learning styles and a more Conference, 1995.
balanced result in the Sensory-Intuitive and Sequential-Global areas. 3. Ouelette R. Learn Styles in Adult Education. University of Maryland,
Table 1 contains the group’s results presented as percentages and 2000.
compared with the results of other studies. 4. Felder R.M. Matters of Style. ASEE Prism, 6:18-23,1996
2003; 96; S-1–S-293 S-98
S-97
SURVEY OF PERSONAL DIGITAL ASSISTANT USE IN most common use reported was for drug reference (71%, n=47),
ANESTHESIOLOGY RESIDENCY PROGRAMS IN THE followed by case log software (62%, n=41), medical calculations (39%,
UNITED STATES n=26), departmental directory (29%, n=19), general medical reference
(29%, n=19), anesthesiology reference (21%, n=14), scheduling (9%,
AUTHORS: A. V. Agarwala1, A. Backus2 n=6), and quality improvement (2%, n=1). Development of proprietary
AFFILIATION: 1UCLA School of Medicine, Los Angeles, CA, software was limited and was reported primarily for case log (16% of
2
UCLA Center for Health Sciences, Los Angeles, CA. programs, n=6) and scheduling (13% of programs, n=5).
DISCUSSION: Though penetration of PDAs as a required tool for
INTRODUCTION: In recent years, medical information has rapidly academic anesthesiologists is low, 90% of respondents reported
expanded and technology has advanced to allow portable electronic voluntarily using such a device. The results suggest that PDAs are
devices to contain vast stores of information. Medical personnel are useful in the academic anesthesiology setting, especially as a drug
now beginning to take advantage of this capacity to optimize patient reference tool and for case log purposes. Thus far, few departments
care and facilitate administrative functions. At the current time, the have developed proprietary software, but this may be expected to grow
pervasiveness of personal digital assistants (PDAs) in academic in the future as the full potential of personal digital assistants is realized.
anesthesia is not known, and information about useful software
programs is communicated by "word of mouth.’ This study aims to
systematically collect information on the use of PDAs in academic
anesthesia settings. The purpose of collecting this information is the
following: 1) to determine how widespread the use of PDAs is in
academic anesthesia, 2) to determine which operating system platform
is preferred, 3) to determine which medical and administrative
functionalities have been facilitated by the use of PDAs.
METHODS: After Institutional Review Board approval, participation
in the study was solicited via email messages sent to representatives
from each of the 132 Anesthesiology residency programs in the US.
Participants completed an email or online survey about PDA use within
anesthesiology residency programs and departments, including types of
hardware and software required or commonly utilized. Participation
was voluntary. Respondents included residents, fellows, faculty, and
program coordinators. Survey data were aggregated and analyzed.
RESULTS: 73 responses from 37 residency programs were obtained.
90% (n=66) reported using a personal digital assistant, with 80% (n=53)
of these using a Palm OS device, 14% (n=9) using a Pocket PC device,
and 6% (n=4) using both types. 32% (n=12) of programs were reported
to require use of a PDA by residents. The average percentage of
residents reported as using a PDA was 72%. The average percentage of
faculty reported as using a PDA was 41%. Of those that use a PDA, the
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BEING BUMPABLE: CONSEQUENCES OFRESOURCE fashion solutions that can withstand both operational pressure and the
SATURATION AND NEAR-SATURATION FOR COGNITIVE threat of future ex post facto evaluations by outsiders. Bumping is
DEMANDS ON ICU PRACTITIONERS neither purely medical nor purely managerial but rather reflects the
synthesis of clinical factors and operational requirements. Successful
AUTHORS: R. I. Cook1, M. Brandwjik1, M. Kahana1, M. O'Connor1, bumping reflects refined practitioner skill and requires substantial effort
V. Brunetti1, C. Nemeth2 in assessment, planning, and coordination (often across service and
AFFILIATION: 1University of Chicago, Chicago, IL, 2Illinois Institute professional boundaries). Unsuccessful bumping creates discontinuity
of Technology, Chicago, IL. of care. [4] This research describes bumping and the associated
cognitive activities and their impact on patient safety.
We report a set of projects that characterize technical work in the setting REFERENCES:
of resource saturation and near saturation (e.g. 100% bed occupancy or 1. Woods DD (1988). Coping with complexity: the psychology of
a full operating room schedule). Cost and resource limitations drive human behavior in complex systems. In Goodstein et al., eds. Task,
ICUs and OR utilization towards saturation. Errors, and Mental Models. NY: Taylor and Francis.
Near-saturation conditions place a premium on practitioner cognition, 2. Barley S, Orr J (1997). Between craft and science: technical work in
especially on the ability to anticipate and prepare to cope with shifting US settings. Ithaca: Cornell.
clinical demands using available resources.[1] The conditions are 3. Klein G (1999). Sources of Power: How People Make Decisions.
regarded as normal and practitioners become adept at coping with them. Cambridge: MIT Press.
One coping strategy, bumping, is remarkable because it is ubiquitous 4. Cook, Render, Woods (2000). Gaps in the continuity of care and
and reflects the contingent and conflicted nature of technical work.[2] progress on patient safety. BMJ 320: 791-
In bumping, a new, high priority demand is accommodated by diverting
resources already in use. In the setting of an ICU, bumping involves
moving one patient out of the ICU in order to allow another one in. In
the operating room, bumping occurs when a scheduled case is held so
that another, more urgent case can go forward. The need for bumping
arises, from the indivisible nature of resources (patients, beds, and
rooms are quanta that cannot be further divided); from the irreducible
uncertainty that pervades healthcare settings; and from the high
consequence and time pressure that characterize acute care settings.
The results from our operating room and the intensive care unit studies
suggest that bumping reflects normal functioning. It is a means for
meeting near-saturation resource demand. Although each location has
formal mechanisms for bumping, these are used to justify rather than
guide practitioner decisions. The requirement for practitioners to meet
the needs of patients plays out as a complicated naturalistic decision
making activity [3] during which practitioners assess conditions,
identify and acknowledge conflicts, forecast future developments and
events, make hedges against uncertainty, and tradeoff goals in order to
S-100 2003; 96; S-1–S-293
S-99
THE EFFECT OF READING ON THE VIGILANCE, CLINICAL anesthesia providers spent significantly more time on record keeping
WORKLOAD, AND TASK DISTRIBUTION OF ANESTHESIA (NR 15.7±1.0% vs. R 5.1±0.9%; p<0.001) and on “Other Care Tasks”
PROVIDERS (i.e., patient care-related manual tasks that did not fall into more
specific categories) (NR 10.8±1.0% vs. R 2.9±0.5%; p<0.001). During
AUTHORS: M. B. Weinger, E. Barker, J. M. Slagle R periods, subjects spent significantly less time performing manual (R
AFFILIATION: University of California, San Diego, CA. 7.2±1.3% vs. NR 19.7±0.9%; p<0.001) and conversational tasks (R
9.7±2.0% vs. NR 16.8±1.6%; p<0.05).
INTRODUCTION: During routine cases, anesthesia providers may DISCUSSION: These results demonstrated that subjects read
read materials that are directly related (e.g., medical records) or selectively during low workload periods and when they did read, their
unrelated to patient care. While some feel this is poor patient care, vigilance was not significantly impaired. This preliminary study
others have argued that reading may obviate boredom that could suggests that reading may have limited effects on vigilance and
otherwise decrease vigilance. To study this issue, behavioral task therefore may not a priori put patient's safety at risk. (Supported by
analysis and workload assessment were conducted to measure the AHRQ & VA HSRD).
effects of reading on vigilance, workload, and task distribution. REFERENCES:
METHODS: After IRB approval and informed consent, 172 general 1. Anesthesiology, 80:77-92, 1994; Anesthesiology, 87:144-155.
routine surgical cases involving general anesthesia were studied. A 2. Physical Work and Effort, 39-47, 1977.
trained observer sat in the OR and categorized the clinician’s activities 3. Proc IEA/HRES Congress, 44:4241-4244, 2000.
into 37 possible tasks 1. Only data from maintenance, the phase in which
all reading occurred, was included in the analysis. The spare capacity of Table 1. Workload Ratings and Vigilance - Maintenance
the anesthesia provider was measured by the time it took for them to Task Reading Non-Reading
respond to a random “vigilance light”. At 7-15 min. random intervals,
psychological workload was measured using a Borg Workload (6 to 20) Observer Workload* 7.6 ± 0.1 (7-11) 8.6 ± 0.1 (7-14)
scale 2, first by the observer and then by the subject. The workload Subject's Workload* 7.9 ± 0.1 (7-12) 8.9 ± 0.1 (7-15)
density was calculated by multiplying the duration of each task actually Workload Density* 0.7 ± 0.04 (0.0-1.9) 1.2 ± 0.02 (0.8-1.4)
performed during the maintenance phase of the case by that task’s
Vigilance Latency 27.9 ± 3.3 (1-207) 29.4 ± 2.3 (1-506)
workload factor score.3 Task data were analyzed using two-way mixed
ANOVA while workload was analyzed using Mann-Whitney U test and Data are presented as mean ± SEM (Min-Max).
vigilance using one-way ANOVA. * = p<0.001, Reading vs. Non-Reading
RESULTS: In 60 of the 172 cases (35%), some intraoperative reading
occurred. In these 60 cases, anesthesia providers read 25±3% of the
maintenance period. When reading, the clinicians spent 44±3% of the
time reading while time-sharing with other tasks. The observer-rated
workload, subject-reported workload and workload density values were
significantly lower during reading (R) than non-reading (NR) periods
(Table). There was no significant difference in vigilance between the
two groups. The distribution of non-reading tasks differed significantly
between R and NR periods in the same case. During NR periods, the
S-100
INFORMATION OVERLOAD: DO ANESTHESIOLOGISTS overload by healthcare-providers, as well as a failure to utilize memory-
EXCEED PATIENTS' CAPACITY TO LEARN? enhancing techniques. Traditionally, greater information-giving has
been favorably viewed in studies of the provider-patient relationship.
AUTHORS: R. Sharma1, E. H. Sandberg1, R. Wiklund2, W. S. When patients are presented with a large quantity of material about the
Sandberg2 anesthetic and operative processes, the question arises of how crucial is
AFFILIATION: 1Suffolk University, Boston, MA, 2Massachusetts it to learn and recall such extensive, specific information? At baseline,
General Hospital, Boston, MA. an average individual can recall approximately seven chunks of new
information (Miller, 1956). Even considering the memory enhancing
INTRODUCTION: Patient education is a critical part of preparation factors built into the context, such as personal relevance and scripted
for surgery. Communication research pertaining to provider-to-patient sequencing, how can an individual possibly be expected to encode 50 to
teaching, though consistently showing deficits, has not been conducted more than 100 medical descriptions and instructions, or to filter and
with a systematic focus on the limits of human learning and memory. recall the most relevant ones? Our application of basic behavioral
Our goal was to quantify the information load given by healthcare science elements to the field of HP-to-patient teaching suggests that
providers (HPs) to patients in a clinical setting, the Pre-admissions reducing information overload should be a goal when conducting the
Testing Area (PATA) at Massachusetts General Hospital. Pre-anesthetic pre-anesthetic consultation. A structured educational content,
consultations in the MGH-PATA are conducted by both nurse reinforced by concise written material could bring the necessary
practitioners (NP) and physicians. We predicted that there would be a information load within the limits of patient’s ability to learn.
difference in the information load presented by NPs and physicians. REFERENCES:
Method: We compared quantitative and qualitative aspects of NPs’ and Miller, G. A. (1956), Psychological Review, 63(2), 81-97.
physicians’ communicative content through the analysis of transcribed
audiotapes of 26 pre-anesthetic consultations. The transcripts were
analyzed according to a novel coding system developed to examine the
HP’s communication patterns with the following categories: quantity of
information, frequency of explained and unexplained medical terms, the
number of patient questions, and the number of reinforcements during
the consultation. Two raters independently coded 100% of the
transcripts.
RESULTS: Comparisons of the physician and NP’s communicative
content with an independent samples t-test indicated that NPs gave
more pieces of information (M = 111.86, SD = 37.16) than physicians
(M = 48.50, SD = 24. 59), t(24) = -5.03, p < .0001. The number of
patient questions did not influence the amount of information given,
t(24) = -.47, p = .64. No significant differences between NPs and
physicians were found in the remaining categories (frequency of
reinforcements, medical terms). Additionally, no significant differences
were detected among any of the provider-patient gender combinations.
DISCUSSION: We observed an extreme tendency toward information
2003; 96; S-1–S-293 S-102
S-101
WRONG SIDED ANESTHETIC AND SURGICAL "paper-checks" such as peri-operative checklists (n=3); laterality specified on
PROCEDURES: ARE THEY PREVENTABLE? consent form (n=6), or institutional laterality policy (n=5). Patient harm
occurred in all cases, and ranged from inconvenience to respiratory arrest, yet
AUTHORS: S. Seiden1, C. Kivlahan2, W. Runciman3, U. Christansen4, P. an incident report was filed in three cases, and full patient disclosure occurred
Barach5 in only four cases.
Risk factors for laterality errors
AFFILIATION: 1Pritzker School of Medicine, Chicago, IL, 2University of Inpatient/ Use of
Consent
form Patient Incident Review of Full disclosure of
Missouri-Columbia, Columbia, MO, 3Royal Adelaide Hospital, Adelaide, ID Age Sex Laterality Error
Outpatient
Workload
checklists indicates Level
laterality
Educ. report laterality Patient Harm
filed error laterality error
Australia, 4Sophus Medical, Copenhagen, Denmark, 5University of Chicago, 1 65 M

Right femoral nerve
block instead of left
Outpatient High Yes No MD No
Yes. Root 24 hr. hospital
cause
stay
Yes
Chicago, IL. Right scalene block High
analysis
Yes. Root
Increased
2 68 F instead of left Outpatient High Yes Yes school Yes cause hospital stay Yes
analysis
INTRODUCTION: Performing a wrong-sided procedure is a tragic event Right axillary block Yes. Root
3 61 F Outpatient High Yes Yes N/A No cause No Yes
for the patient and the surgical team. However, bilateral symmetry of organs instead of left analysis
Yes. Root
creates the potential for wrong- sided anesthesia and surgery, especially for 4 25 M
Right leg 3-1 block
instead of left Outpatient High N/A Yes N/A No cause No
Yes. Mother
informed
analysis
percutaneous blind procedures such as nerve blocks. Research has Left Carotid/neck < High Resp. arrest No. Internist told
5 70 F blocked instead of Inpatient Normal No Yes Yes N/A and use of pt, surgical team
documented the prevalence of wrong-sided surgeries but investigation of right School ventilator did not.
Right lower quadrant Yes.
wrong-sided anesthesia is lacking. To prevent adverse events we must first 6 50s F incision instead of Inpatient High No Yes
High
school Yes N/A Unnecessary No
left incision.
understand how and where the systems and predictable cognitive failures Right breast Yes. Unknown, but pt
Yes, but Yes. Root Unnecessary
occurred. This requires a comprehensive understanding of the environments 7 81 F localization needle
inserted instead of
Outpatient High N/A maybe N/A No cause right breast concious
throughout
incorrect analysis needle
and behavioral circumstances surrounding adverse events, the epidemiology left breast
insertion
procedures.
of such events, and the development of systemic, environmental and DISCUSSION: While only seven cases are presented, the lack of other
behavioral mechanisms to prevent the recurrence. From 1995-2002 the studies on the risk factors and epidemiology of wrong-side procedures make
JCAHO identified 197 wrong-site procedures accounting for 11.3% of these cases significant. Trends worthy of further investigation include the
reported adverse events,[1] and the Physician's Insurance Association of apparent ineffectiveness of "paper" based protections against laterality errors.
America includes 1000 closed claims involving wrong-sided procedures.[2] In addition, the preponderance of older aged patients, regional anesthesia, and
Database analayses identified as risk factors: multiple procedures and outpatient, high-workload environments, all warrant further study. These data
surgeons during one operating room trip, unusual anatomy, and time demonstrate that latent errors lie dormant and are realized when conditions
constraints.[2] Estimates suggest that voluntary reporting underestimates the become rifht for thier expression. Educational and preventive strategies that
incidence of wrong-sided events by a factor of 20 or more.[2] focus on cognitive and systems issue may have great potential in enhancing
METHODS: Descriptive epidemiologic series of seven cases from hospitals the safety of anesthetic care. Systems practices to successfully reduce wrong-
in Denmark, United States, and Australia comparing wrong-sided procedures sided procedures will likely combine a standard method of sidedness marking
according to factors associated with the event. supported by a collaborative team and systems effort.
RESULTS: Preliminary results (see table 1) suggest that the risk factors for REFERENCES:
performing a wrong-sided procedure include: ambulatory surgery setting [1] JCAHO, Sentinel Event Statistics, http://www.jcaho.org/
(n=5); older age (n=6); female gender (n=5); left-sided procedure (n=6); accredited+organizations/ambulatory+care/sentinel+events/se_stats.htm,
regional anesthesia (n=6); and morning surgery during high clinic workload Accessed September, 6, 2002.
(n=6). The involvement of multiple team members including residents, [2] AHRQ, “Making Health Care Safer” http://www.ahcpr.gov/clinic/
attendings and nurses (n=7) did not prevent laterality errors, nor did existing ptsafety/chap43b.htm#43. Accessed September, 6 2002.
S-102
FACTORS CONTRIBUTING TO HUMAN ERRORS BY SYSTEM HUMAN
ANESTHESIA PROVIDERS NON SYSTEM ERROR HUMAN ERRORS
ASA1 CAY
AUTHORS: S. Ramachandran1, E. J. Lehning2, R. S. Lagasse2 ERRORS ERRORS INCIDEN ERRORS INCIDEN
AFFILIATION: 1Albert Einstein College of Medicine/Montefiore CE% CE%
Medical Center, Bronx, NY, 2Albert Einstein College of Medicine/ 1 8319 77 0.916 6 0.071 *
Montefiore Medical Center, Bronx, NY. 2 10506 63 0.596 1 0.009
INTRODUCTION: Approximately 10 % of adverse perioperative 3 6811 62 0.901 2 0.029
outcomes are due to human errors by anesthesia providers(1). The ATT 27056 174 0.639 3 0.011
authors investigate the effects of anesthesia provider training and ASA 2 1 7189 175 2.372 14 0.189 *
concurrent patient disease on human error rates.
METHODS: Adverse perioperative outcomes at two university- based 2 15172 131 0.856 7 0.045
hospitals between Jan 1st 1998 and July 31st 2002 underwent a 3 14432 132 0.906 5 0.034
previously described peer review process to determine the human error ATT 53789 559 1.028 20 0.036
contribution(1).All anesthetics involved direct patient care and / or
supervision by an attending anesthesiologist. Human error rates, ASA 3 1 7645 191 2.431 20 0.254 *
stratified by anesthesia provider training and ASA physical status (ASA 2 7381 126 1.676 10 0.133
PS), were examined using contingency tables and statistical 3 7288 129 1.737 9 0.121
significance was determined using Pearson chi square test.
RESULTS: Human errors by anesthesia providers increases ATT 27920 524 1.840 24 0.084
logarithmically with increasing ASA PS. CAY 1 anesthesia providers ASA 4 1 637 39 5.718 6 0.879 *
have higher human error rates than other anesthesia providers at all 2 2131 68 3.088 3 0.136
levels of ASA PS.
3 2621 68 2.526 3 0.111
ATT 5708 231 3.882 11 0.184
ASA 5 1 33 14 29.166 1 2.083 *
2 87 19 17.924 0 0.000
3 139 15 9.740 0 0.000
ATT 282 57 16.666 1 0.294
DISCUSSION: Level of training and ASA PS affect human error rates
of anesthesia providers, despite supervision by attending
anesthesiologists.
REFERENCES:
Anesthesiology, 82(5): 1181- 1188, 1995
S-104 2003; 96; S-1–S-293
S-103
EVALUATION OF HOUSESTAFF AND MEDICAL STUDENT and the safety culture and barriers scales (r=0.52, p=0.002). Those
ATTITUDES TOWARDS ADVERSE MEDICAL EVENTS exposed to adverse events reported a lower overall awareness of safety
culture (p=0.039).
AUTHORS: P. Vohra1, C. Daugherty2, M. Wen2, J. Mohr2, P. Barach2
AFFILIATION: 1University of Chicago Pritzker Medical School, Internal Consistency Reliability Coefficients, Means, and SDs
Chicago, IL, 2University of Chicago, Chicago, IL. Scale No. of Items Cronbach's alpha Mean (SD)
INTRODUCTION: There has been a renewed interest in reducing Knowledge 7 0.73 66 (14.3)
medical errors and improving patient safety[i]. One mission of Self-Efficacy 5 0.80 66 (21.3)
academic hospitals is to reach exceptional levels of patient care
education for medical students and housestaff. There has been little Safety Culture 10 0.82 78 (15.5)
previous research on housestaff and medical errors[ii]. This study Barriers/Facilitators 6 0.75 47 (18.2)
examines the process by which physicians-in-training (PITs-medical Human Factors 6 0.57 49 (8.1)
students and housestaff) respond to adverse events in patient care and
incorporate lessons into their practice at a city teaching hospital. DISCUSSION: Preliminary results suggest that the exposure of PITs to
METHODS: We recruited 700 PITs to complete an anonymous medical errors affects their attitudes and behavior toward patients.
electronic questionnaire on a secure website. Questions assessed Exposure of respondents to events may decrease error reporting and
knowledge of methods to improve patient safety, beliefs in their ability willingness to adopt safety practices. 25% of respondents were unaware
to reduce medical errors, and their experiences with adverse events. of error reporting systems. The low means on human factors and safety
Questions were categorized using an affinity sort into five scales: barriers scales suggest the need for a formal safety curriculum. PITs
knowledge, self-efficacy, awareness of safety culture, beliefs about with confidence in their ability to improve patient safety may have a
barriers/facilitators, and awareness of human factors. Each category more accurate view of the barriers and facilitators to error reduction and
was scored on a 100-point scale; summing the five scales formed the display more patient safety-promoting behaviors than PITs with less
Patient Safety Score (PSS) with a 500-point maximum. Multivariate confidence. The learning experience of housestaff exposed to errors has
regression analyses were performed to examine the influences of not been positive and the lessons have not been incorporated formally
independent variables such as department, level and length of post- into their training. A patient safety curriculum that helps PITs learn
graduate training, and previous adverse event exposure on the PSS. from adverse events is needed.
Pairwise Pearson correlation coefficients were obtained for the scales. REFERENCES
Two sample t test was conducted to compare those exposed to adverse [i] To Err is Human,1999.
events with their counterparts. [ii] Journal on Quality Improvement. 1996; 22: 640.
RESULTS: Preliminary analysis of this ongoing survey of respondents
to date (response rate of 4.7% (n=33)) demonstrates that 45.5% had
been exposed to an adverse event (n=15) and 21.2% (n=7) had attended
a Adverse Event meeting. Mean PSS score was 303 (SD=52).
Demographic data or training program did not influence PSS score. The
self-efficacy scales were positively correlated with knowledge (r=0.41,
p=0.017), safety culture (r=0.56, p<0.001), barriers (r=0.73, p<0.001),
S-104
ROLE OF ANESTHETIC CARE IN UNEXPECTED ASA Classification Number of cases Number of deaths Frequency (%)
PERIOPERATIVE DEATHS IN VETERANS AFFAIRS
1 23,333 0 0%
HOSPITALS
2 165,955 12 0.007%
AUTHORS: J. E. Souders1, M. J. Bishop1, K. B. Domino1, S. Khuri2, 3 240,448 135 0.056%
W. G. Henderson3, J. Daley4
AFFILIATION: 1VA Puget Sound Health Care System and the Of the 52 charts reviewed, anesthetic care was possibly contributory in
University of Washington School of Medicine, Seattle, WA, 2VA 18 deaths. Anesthetic care was strongly contributory in 8 deaths, and all
National Surgical Quality Improvement Program and West Roxbury VA were ASA 3. ASA 3 patients were seven times more likely than ASA
class 2 patients to die within 24 hours of elective surgery (p<0.01, chi-
Medical Center, Boston, MA, 3VA National Surgical Quality square). It is notable that in 5 of these 8 patients (62.5%), the adverse
Improvement Program and the University of Colorado Health Sciences event occurred during patient transfer from the operating room.
Center, Denver, CO, 4VA National Surgical Quality Improvement DISCUSSION: ASA classification remains important in determining
Program and Tenet Health, Dallas, TX. the relative risk of elective surgery. This study found that deaths in the
intra-operative and immediate post-operative period have a relatively
INTRODUCTION: Death within 24 hours of elective surgery is an small likelihood of being related to anesthesia care. There were no
uncommon event for ASA Class 1-3 patients. We hypothesized that intraoperative deaths attributable to unexplained hypoxemia,
anesthesia-related problems would constitute a significant proportion of hypotension, or arrhythmia. This contrasts with older data from the
such deaths. The National VA Surgical Quality Improvement Program American Society of Anesthesiologists Closed Claims Project. Of
(NSQIP) is a prospective, multicenter, observational study of risk- interest is the number of adverse events that occurred during the transfer
adjusted surgical outcomes in 123 hospitals. Our goal was to use this of the patient in the immediate postoperative period. The end of the case
database to ascertain whether identifiable patterns of operative deaths may be a critical period for improvement in the quality of anesthetic
emerge that could improve anesthetic care. care during major surgical procedures. Supported by a grant from the
METHODS: Elective operations performed on ASA 1-3 patients under VA Epidemiology Research Information Center.
general, spinal, and epidural anesthesia from 1995-99 were eligible for
inclusion. There were 147 deaths within 24 hours of surgery. Fifty-two
charts for ASA 2 and 3 patients were obtained and reviewed by two
anesthesiologists experienced in quality assurance reviews. The role of
the anesthetic care in the death was judged as follows: strongly
contributory, possibly contributory, non-contributory, or impossible to
judge.
RESULTS: ASA physical classification was a strong predictor of the
risk of death within 24 hours of surgery. There were no ASA 1 patients
among the 147 deaths recorded in the 5-year period studied.
2003; 96; S-1–S-293 S-106
S-105
THE GAS USAGE MONITOR OF THE DATEX-OHMEDA S/5 mark and 180% more by the 120-minute mark.
ADU DIGITAL ANESTHESIA MACHINE FACILITATES
TEACHING OF CLOSED CIRCUIT ANESTHESIA
AUTHORS: J. M. Weaver1, B. L. Arron2, S. M. Eleff3
AFFILIATION: 1University of Chicago, Chicago, IL, 2Mt. Sinai
Medical Center, Chicago, IL, 3Finch University of Health Sciences/The
Chicago Medical School, Chicago, IL.
INTRODUCTION: The Datex-Ohmeda S/5™ Anesthesia Delivery
Unit is a newly available digital anesthesia machine capable of real-
time measurement in 5-milliliter increments of liquid volatile agent
consumed. We propose this machine is well suited to use as an
educational tool for teaching the concept of closed circuit anesthesia.
The benefits of closed circuit anesthesia are well described in several
review articles (1) (2). However, 90% of anesthesia practitioners use
fresh gas flow rates between 2 to 5 L/min (1). Combining these high
flow rates with volatile agents such as desflurane may needlessly
increase costs. Therefore, based on the new ACGME core competency
of systems-based practice, residency programs should increase efforts
to teach the technique of closed circuit anesthesia.
METHODS: After IRB approval, a team consisting of experienced and DISCUSSION: The volatile agent usage feature of the Datex-Ohmeda
inexperienced closed circuit anesthesia providers completed ten S/5™ ADU offers a new and easy to use educational tool for teaching
anesthetics. All patients received a general endotracheal tube anesthetic closed circuit anesthesia concepts. The integrated gas analyzers and
with IV induction of the practitioner‘s choice and then maintenance digital fresh gas flow settings allowed all five practitioners to
with desflurane. The initial wash-in phase employed high gas flows of 6 participate in this study on their first attempt. The experienced
L/min until the end-tidal desflurane concentration reached the anesthesia providers found the real-time gas usage data invaluable in
practitioner‘s choice of 0.8 to 1.3 MAC. The remainder of the teaching the inexperienced providers closed circuit anesthesia. The gas
anesthetic was maintained at 0.8 to 1.3 MAC with either a 2 L/min usage monitor allowed for direct comparison of the two anesthetic
(medium flow) or a 0.25 L/min (closed circuit) fresh gas flow of O2. techniques, and all practitioners revealed that the amount of volatile
The data was monitored by the practitioner using the ADU‘s gas usage agent saved with a closed circuit was much greater then they would
monitor at 5, 10, 15 minutes and for 15 minute intervals thereafter. have predicted. Because of the learning experience provided by this
RESULTS: All practitioners easily collected the data on the first study, the inexperienced practitioners are now using closed circuit
attempt and reported similar results. The data were averaged to produce anesthesia with selected patients.
the graph. The average ml of desflurane used in the first thirty minutes REFERENCES:
for both techniques was similar. When compared to the closed circuit, 1). Canadian Journal of Anaesthesia, 44:6, pp.643-53, 1997.
the medium flow technique used 72% more desflurane by the 60-minute 2). Anaesthesia, 50, pp.37-44,1995.
S-106
CODING PERMUTATIONS MAY BE REDUCED PRIOR TO RESULTS: Independent factors CPTAB and Anes explained 89% of
MODELING OF DUAL PROCEDURE SURGERIES the variability in lnTT. The interaction CPTAB * Anes was not tested
because many surgeries were associated with a single type of
AUTHORS: D. P. Strum1, J. H. May2, L. G. Vargas2 anesthesia, i.e. general. All other first order interactions were not
AFFILIATION: 1Queen's University, Kingston, ON, Canada, significant. Permutations of dual procedure surgeries did not differ with
2
University of Pittsburgh, Pittsburgh, PA. respect to lnTT.
CONCLUSIONS: Permutations do not appear to represent statistically
INTRODUCTION: Better time estimates are important to improve distinct procedures (in any systematic way) with respect to TT. This
surgical scheduling and reduce operational costs. Multiple procedure result implies that sample sizes may be increased and scheduling
surgeries are difficult to model because experience with them is sparse estimates improved if coding permutations are reduced prior to
and because coding permutations (order dependent combinations of modeling of dual procedure surgeries.
similar CPT codes) exist that further reduce the case numbers available REFERENCES:
to model. To determine if permutations should be modeled separately or 1. Bashein et al: Anesthesia Analgesia 1985; 64:425-431.
reduced, we tested if coding permutations represent statistically 2. Strum et al: Anesthesiology 2000; 92:1160-67.
different surgeries with respect to total surgical time (TT).
METHODS: With institutional approval, we studied 10,740 dual ANOVA Table (r2 = 89%, n = 1,862 surgeries, 336 CPTAB combinations)
procedure surgeries each with 2 different component CPT codes
performed at a large teaching hospital (1). Each dual procedure surgery Factor Sum Squares DF MSE F-Ratio P value
(CPT1-2) was provider designated by combinations of 2 procedures CPT-AB 443.671 59 7.520 112.242 0.0000
(CPT1-2). Permutations were observed in which the order of the same 2 Anes 17.657 3 5.882 87.798 0.0000
component codes was reversed (i.e. CPT1-2 coexisted with similar
surgeries CPT2-1). To explore differences in TT, we reordered provider Perm 0.036 1 0.036 0.537 0.4637
assigned codes (CPT1-2) arbitrarily to eliminate permutations. The new Perm * Anes 0.073 3 0.024 0.362 0.7806
order of CPTs (CPTA-B) was determined by ordering the CPT with the Perm * CPT-AB 3.670 59 0.062 0.929 0.6304
greatest numeric value of the CPT as CPTA and that with the lessor
numeric value as CPTB. Because the numeric values for CPT codes are Error 111.307 1736 0.067
assigned on anatomic and pathologic grounds, we considered the values
of the codes are arbitrary with respect to TT. Permutations were
identified by comparison of the provider ordered and numeric value
ordered codes. To investigate systematic differences among
permutations with respect to TT, we fit an aggregate linear model of the
form:
lnTT = CPTAB + Anes + Perm + Error
where lnTT = natural log of TT (2), Perm = 0 if CPTA > CPT1 and
Perm = 1 if CPTA < CPT1 numerically, and Anes = categorical variable
for type of anesthesia. Only 336 CPTA-B combinations had coding
permutations.
S-108 2003; 96; S-1–S-293
S-107
FACTORS AFFECTING THE VARIABILITY OF TIME ordered by decreasing importance (by factor F-ratio) were MTE1,
ESTIMATES FOR DUAL PROCEDURE SURGERIES MTE1, Anes, Emerg, Age, SPEC1, and SPEC2. Results were similar
for ST.
AUTHORS: D. P. Strum1, J. H. May2, L. G. Vargas2 CONCLUSIONS: This research identifies factors associated with
AFFILIATION: 1Queen's University, Kingston, ON, Canada, variability in dual procedure surgeries. Knowledge of the sources of
2
University of Pittsburgh, Pittsburgh, PA. variability is needed to improve modeling of multiple procedure
surgeries and to improve surgical schedules.
INTRODUCTION: Better estimates of surgical times are needed to REFERENCES:
improve scheduling and reduce costs. Surgeries comprised of exactly 1. Strum et al: Anesthesiology 2000; 92:1160-67.
one surgical procedure (CPT) have been modeled using the lognormal 2. Bashein et al: Anesthesia Analgesia 1985; 64:425-431.
model (1). Modeling of dual procedure surgeries (CPT1-2) is more
difficult because these surgeries are less common and conventions do ANOVA Table for lnTT (r2 = 68.7%, n = 9,876 CPT-12 surgeries)
not exist to model them. It is logical to assume that times estimates for
CPT1-2 surgeries may be constructed using estimates derived from Factor Sum Squares DF Mean Square F-Ratio P value
component CPTs. We studied CPT1-2 surgeries and their component MTE1 780.90 1 780.90 6064.18 0.0000
CPTs to identify factors associated with variability in dual procedure MTE2 110.60 1 110.60 858.88 0.000
surgery times.
METHODS: With institutional approval, we studied, retrospectively, Anes 61.42 3 20.47 160.00 0.0000
10,737 CPT1-2 surgeries and 46,322 single CPT surgeries performed at Emerg 2.34 1 2.34 18.18 0.0000
a large teaching hospital (2). CPT1-2 surgeries were named jointly for Age 1.47 1 1.47 11.46 0.0007
both procedures, one designated 1st (CPT1) and the other 2nd (CPT2).
We used multivariate linear models to study some factors that affect SPEC1 15.36 17 0.90 7.01 0.0000
variability in total time (TT) and surgical time (ST) for CPT1-2 SPEC2 11.54 18 0.64 4.98 0.0000
surgeries. To do this, we fitted a 7-factor main effects model of the Error 1266.22 9833 0.13
general form:
lnTT = MTE1+MTE2+Anes+Emerg+Age+SPEC1+SPEC2+error
where MTE1 = median time estimate for CPT1, MTE2 = median time
estimate for CPT2, Anes = type of anesthesia, SPEC1 = surgical
specialty of CPT1, SPEC2 = surgical specialty of CPT2, Emerg =
emergency status (yes or no), and age. We conducted the analyses using
the natural logarithm (ln) of TT and ST because of previous indications
of lognormality (2). To provide MTEs, single CPT surgeries were
summarized by their medians and matched to CPT1-2 component codes
using lookup tables. Surgical specialties (1-20) were assigned using
main headers from the CPT classification.
RESULTS: All 7 independent factors were significant (p < 0.05) and
together explained 69% of the variability in lnTT. Independent factors
S-108
THE RELATIONSHIP BETWEEN SELECTED RISK FACTORS length of surgery (p = 0.003) advancing age (p = 0.002), female gender
AND ADVERSE OUTCOMES IN PATIENTS UNDERGOING (p =0.0096), history of arrhythmia (p = 0.0006), myocardial infarction
THORACIC, OTOLARYNGOLOGIC, ORTHOPAEDIC, in the past six months (p = 0.0304), and type of anesthesia (p = 0.0023).
UROLOGIC, AND GENERAL SURGERIES The logistic regression model for cardiovascular complications was also
significant (likelihood chi-square ratio = 170.19, df = 46, p < 0.0001,
AUTHORS: N. Naughton, M. V. Greenfield, K. B. Welch, P. Benedict, Nagelkerke r-square = 0.10); significant predictors of cardiovascular
M. O'Reilly, J. Rosenberg complications were increased length of surgery (p = 0.0003), advancing
AFFILIATION: The University of Michigan, Ann Arbor, MI. age (p < 0.0001), history of arrhythmia (p < 0.0001), myocardial
infarction in the past six months (p = 0.037), and coronary artery
INTRODUCTION: The goal of this study was to create models to disease (p = 0.0084).
predict post-operative complications in surgeries generally considered DISCUSSION: Both models revealed unexpected associations: In the
to have very low complication rates. all complications model, women were 1.5 times more likely to have
METHODS: This study examined 48,550 patients aged 13 to 101 years complications compared with men; odds of complications were greater
(mean age 49.7) at the University of Michigan Health System who with general anesthesia than with central neurologic blockade (1.9), and
underwent thoracic, otolaryngologic, orthopaedic, urologic, or general general anesthesia combined with peripheral (3.5) or combined with
surgery from 1995 to 2000. A logistic regression model was used to central blockade (2.7). In both models, patients having a surgery length
examine predictors including age, gender, tobacco use, sleep apnea, risk between 5-6 hours had the greatest odds of having complications even
of aspiration, arrhythmia, asthma, diabetes, heart failure, hypertension, when compared with surgeries lasting much longer. Lack of
recent myocardial infarction, obesity, central nervous system disorders, significance (in either model) for diabetes, hypertension, or obesity was
congenital heart disease, chronic obstructive pulmonary disease, and noteworthy.
diseases of the coronary arteries, liver, or kidneys. Also considered
were surgery duration and type of anesthesia administered. Outcomes
studied were unanticipated difficult airway, reintubation, cardiac arrest,
death, myocardial infarction, significant dysrhythmia, central nervous
system injury, aspiration, and respiratory arrest. All analyses controlled
for year of surgery and surgical service. One model studied all
complications; a second model was limited to cardiovascular
complications. To study individual risk factors, we excluded ASA
status. Emergency surgeries or ASA status >=5 were excluded.
RESULTS: There were 252 (252/49,550 or 0.5%) surgeries with a least
one complication, and of these 125 (125/49,550 or 0.25%) had
cardiovascular complications (myocardial infarction, cardiac arrest,
significant dysrhythmia, or death). The logistic regression model for all
complications was significant (likelihood chi-square ratio = 179.72, df
= 47, p < 0.0001, Nagelkerke r-square = 0.06). Taking all predictors of
complications together and controlling for year of surgery and service,
this model revealed the following significant predictors: increased
2003; 96; S-1–S-293 S-110
S-109
THE CHARLSON COMORBIDITY SCORE AS AN 2, and >2 points. Distinguishing ASA>2, CCS>0, and CCS>1 (each as
ALTERNATIVE TO THE ASA PHYSICAL STATUS evaluated as an individual cohort) from all other patients were presence
CLASSIFICATION of clinically important medical diagnoses. These three comorbidity
cohorts individually were also associated with increased LOS of 14-
AUTHORS: F. K. Orkin 19% and increased Charges, 22-43% (all, P <0.001).
AFFILIATION: PennState University College of Medicine, Hershey, DISCUSSION: CCS has face validity resembling ASAPS as a
PA. descriptor of important comorbidity and as a predictor for adverse
outcomes. CCS should be evaluated further along with ASAPS as a
INTRODUCTION: ASA Physical Status Classification (ASAPS) stratification variable in outcomes comparisons using observational
enjoys widespread use as a convenient and valid way to characterize data sets.
patient health status and risk for mortality and morbidity in relation to 1
Charlson ME, et al. J Chron Dis 1987;40:373-83.
anesthesia and surgery. Yet, classifying patients’ health status may be
somewhat subjective, and ASAPS is generally not recorded in
observational databases increasingly used for outcomes research. A
potential alternative is the Charlson Comorbidity Score (CCS) whose
additive ‘points’ reflect the presence of specific, clinically important
medical diagnoses commonly present in observational databases. CCS
is predictive of death within one year1 and has been used and validated
in outcomes research in general medicine. This study evaluates
usefulness of CCS as an alternative to ASAPS in outcome comparisons
among surgical patients.
METHODS: A quality-improvement project team created an
observational database of 832 consecutive major joint arthroplasty
procedures performed in the mid-1990s. Among data were
postoperative length of stay (LOS), adjusted hospital charges (Charges,
from institutional financial system), ASAPS (from anesthetic record),
presence of the 18 medical diagnoses (e.g., myocardial infarction,
congestive heart failure, chronic pulmonary disease, diabetes mellitus
with complications) used for computing CCS,1 and CCS. Summary
statistics, Spearman rank-order correlation analysis, parametric (t-test)
and nonparametric (Mann-Whitney U test) comparison of means, and
linear discriminant analysis were used to compare ASAPS and CCS
values and two outcomes in this dataset.
RESULTS: CCS correlated modestly (r 0.45) with ASAPS, reflecting
differences in patient distributions: 4.4%, 59.3%, 33.5%, and 2.8% of
patients were distributed among ASAPS Classes 1 to 4, respectively;
whereas 66.7%, 20.8%, 7.8%, and 4.7% were spread among CCS 0, 1,
S-110
RATIONAL MEDICAL DECISION MAKING IN increase in d/vC by €€ 40,087 (36%) (from €€ 112,116 to 152,203).
AUTOLOGOUS TRANSFUSION IMPROVES EFFICACY AND Increase in number of PABDs p. pat. together with increase in time-
COST-EFFICIENCY. interval between first PABD and surgery from 14 to 36 days resulted in
an increase in +RBC by 208% (from 81 ml in ATC I to 250 ml p. pat. in
AUTHORS: G. Singbartl1, W. Schleinzer2, H. Munkel1 ATC II). This increase in +RBC equalled to gaining of additional 2,006
AFFILIATION: 1AIT - ENDO-Klinik Hamburg GmbH, D-22767 RBC-U, and net-improvement in cost-efficiency of €€ 89,468.
Hamburg, Germany, 2IFAS - Swiss Paraplegic Center, CH-Nottwil, Cancellation of APPH in ATC II reduced d/vC by €€ 468,289.
Switzerland. Considering APPH on coagulation reasons with 20% and the remaining
units a volume substitute (80%), and replacing them by an artificial
INTRODUCTION: Limitation of resources of the public health colloid, reductions in d/vC still amounted to €€ €€ 237,469. Total savings
system urge clinicians to reconsider their clinical practice. This study by ATC II amounted to €€ 534,357.
analyses its impact on cost-efficiency (CE) of peri-operative blood- DISCUSSION: Rational medical decision making concerning
salvage with mechanical processing (BS), pre-operative autologous autologous transfusion measures was associated with an increase in
blood donation (PABD), and autologous plasmapheresis (APPH) before efficacy and considerable improvement of cost-efficiency.
(ATC I) and after (ATC II) changing the autologous transfusion concept
(ATC).
METHODS: Contrary to ATC I with deliberate indication for BS,
PABD, and APPH, in ATC II BS and PABD were applied only, if an
increase in RBC mass (+RBC) of at least 1 RBC-U (190 ml) was
expected; APPH was cancelled. Calculations concerning APPH
considered it with 20 % on coagulation reasons and 80 % a
intravascular volume substitute; it was replaced by an artificial colloid.
Since basics for fixed cost did not change, in order to avoid
disturbances due to changes in charges to be paid by the hospital, and to
make comparisons easier, CE exclusively considered direct / variable
cost (d/vC) inclusive disposables, consumables, volume substitutes,
type, screen, infectious / serological testing. Thus, identical measures
caused identical d/vC in ATC I and II (BS: €€ 188.10. PABD: €€ 36.05 p.
1 PABD, €€ 60.10 p. 2 PABDs: APPH: €€89.10); 1_ = 1$.
RESULTS: Comparing BS in ATC II vs. I, number of BS-sets
consumed decreased by 30.6% (from 2,690 to 1,866) resulting in a
decline in d/vC by €€ 154,994 (from €€ 505,989 to €€ 350,994). Number of
processing-cycles p. pat. increased from 1.98 to 2.54, increasing +RBC
by 63 ml p. pat. (from 223 to 286 ml). Reduction in BS-sets consumed
and increase in efficacy improved CE of BS by €€ 207,420. Concerning
PABD in ATC II vs. I, number of PABDs increased by 62.9% (from
3,110 to 5,065); i. e. from 1 to 1.95 PABDs p. pat., thereby causing an
S-112 2003; 96; S-1–S-293
S-111
ONLY TWO CLINICAL PARAMETERS ARE OF DECISIVE and 2 PABDs (II) were as follows: Hct: 228.0**(I); 42.3**(II). T – S:
IMPACT ON INCREASE IN TOTAL RBC-MASS BY PRE- 69.6**(I); 27.8**(II). BV coll: 1.6(I); 0.7(II). Gender: 7.3**(I);
OPERATIVE AUTOLOGOUS BLOOD DONATION – A 0.04(II). Age: 0.2(I); 5.6(II). EBV: 0.9(I); 2.4(II). ASA-Score: 1.7(I);
PROSPECTIVE STATISTICAL ANALYSIS IN 704 PATIENTS 0.2(II). Corresponding results concerning CC and PCC were found:
+RBC vs. T – S: I: CC r = 0.353**; PCC r’ = 0.323**. II: CC r =
AUTHORS: G. Singbartl, K. Schueler, H. Munkel 0.342**; PCC r’ = 0.303**. +RBC vs. Hct: I: CC r = -0.487; PCC r’ = -
AFFILIATION: AIT - ENDO-Klinik Hamburg GmbH, D-22767 0.581**. II: CC r = -0.380**; PCC r’ = -0.467**.
Hamburg, Germany. DISCUSSION: These data reflect the importance of adopting the
PABD-program to the physiologic basics if erythropoiesis: 1st a long
INTRODUCTION: Pre-operative autologous blood donation (PABD) time interval between last PABD and surgery in order to enable an
is an established measure to reduce the need for allogeneic blood. appropriate RBC-regeneration. 2nd to collect a larger volume of RBC-
However, to make it an efficacious, effective and cost-efficient mass (than the so far routinely collected equivalent of only 1 RBC-unit
alternative to allogeneic blood transfusion, it is important to know those per PABD-session) on less PABD-sessions in order to lower more
clinical parameters that are of impact on increase in RBC mass (+RBC). effectively the pat.’s hct to an individually adopted anaemic hct level,
METHODS: Prospective data analysis with IRB-approval concerning and, thereby, stimulate erythropoiesis as strong as possible.
+RBC by PABD in 704 pats. (with either one or two PABDs) scheduled
for major orthopaedic surgery. +RBC was analysed with respect to age,
gender, patient’s estimated blood vol. (EBV), blood vol. collected (BV
coll) on each PABD-session, ASA-score, time-interval between PABD
and surgery (T – S [days]), and hct on PABD-session. EBV was
calculated according to Nadler. Pat.’s RBC-mass resulted from
EBV*systemic hct. +RBC by PABD1 (+RBC1) was obtained from
RBC-mass on visit2 (RBC2) minus RBC-mass on visit 1 (RBC1) plus
RBC-mass harvested on PABD-session1. +RBC2 was calculated from
RBC-mass preop. minus RBC-mass on visit2 plus RBC-mass collected
on PABD-session2. Statistical analysis was performed by univariate
multiple analysis of variances, correlation analysis (correlation
coefficient – CC, and partial correlation coefficient – PCC), ANOVA
with Scheffe´-test; statistical significance was considered with p <
0.01** with Bonferroni correction.
RESULTS: Only two parameters were demonstrated of consistent (i.e.
in patients with either one or two PABDs) and decisive impact on
+RBC: T – S which correlated positively with +RBC, and hct on PABD
which correlated negatively with +RBC. Gender correlated only
inconsistently with +RBC (i.e. in pats. with 1 PABD only). Age, EBV,
and ASA-score did not correlate with +RBC. Corresponding data (F-
values) of multiple, univariate analysis concerning +RBC in 1 PABD (I)
S-112
ADOPTING PREOPERATIVE AUTOLOGOUS BLOOD days). In the subgroups of 2 SCU, time-interval between PABD1 and
DONATION TO THE PHYSIOLOGIC BASICS OF PABD2 (T1 – 2) was 14 ± 1 days, and between PABD2 and surgery (T2
ERYTHROPOIESIS IMPROVES INCREASE IN TOTAL RBC – S) 13 ± 2.4 days. However, total +RBC was greater (p<0.000) in DD
MASS than in 2 SCU (261 ± 114 vs. 168 ± 133 ml). In 2 SCU, +RBC and
+RBC2 were not different (89 ± 119 and 79 ± 119 ml).
AUTHORS: G. Singbartl1, M. Schnelle2, H. Munkel1, A. Quoss2 DISCUSSION: Though no differences were demonstrated concerning
AFFILIATION: 1AIT - ENDO-Klinik Hamburg GmbH, D-22767 base data and total time-intervals in 2 SCU vs. DD, total +RBC was
Hamburg, Germany, 2Anaesthesieabt. / Eigenblutbank - Rheumaklinik, higher (p<0.000) in DD than in 2 SCU. Both the longer time-interval for
Bad Bramstedt, Germany. T – S in DD compared to those of the two separate time-intervals T1 –
2, and T2 – S in 2 SCU, and the stronger decline of hct in DD due to
INTRODUCTION: Only two clinical parameters were demonstrated collecting a greater RBC-mass on only one PABD-session are
of impact on RBC-regeneration (+RBC) due to preoperative autologous considered the underlying mechanisms of these results. Thus, adopting
blood donation (PABD): 1st time-interval between blood donation and the PABD-concept to the physiologic basics of erythropoiesis improves
efficacy of PABD. (This analysis was supported in part by a grant from
surgery (T – S), that correlated positively with +RBC; 2nd hct-level on Haemonetics GmbH, Munich, Germany).
PABD, that correlated negatively with +RBC. Thus, collecting the
equivalent of two PABDs on one session (double deposit - DD) should
optimise efficacy of PABD when compared with that of two separately
collected units (2 SCU) on two separate PABD-sessions.
METHODS: Prospective preference study with IRB-approval in pats.
scheduled for major orthopaedic surgery (DD: n=100. 2 SCU: n=60).
Blood volume collected was 860 ml in DD, and 2*430 ml in 2 SCU.
Pat.’s blood volume (EBV) was calculated according to Nadler. RBC-
mass was calculated with EBV*systemic hct. In DD, +RBC resulted
from RBC-mass pre-op. minus initial RBC-mass plus RBC mass
collected by DD. In 2 SCU, +RBC1 by PABD1 was calculated from
RBC-mass on PABD2 minus RBC-mass on PABD1 plus RBC collected
on PABD1; +RBC2 resulted from RBC-mass pre-op minus RBC-mass
on PABD2 plus RBC-mass collected on PABD2. Statistical analysis
was performed by t- / U- / H-test, ANOVA with Scheffe’s test;
statistical significance was considered with p<0.05 with Bonferroni’s
correction.
RESULTS: No differences were demonstrated between patients with 2
SCU vs. DD concerning base parameters (gender, age, height, weight,
EBV, hct init, RBC-mass init). Referring to ‘blood data’, no differences
were demonstrated concerning total RBC-mass collected (2 SCU vs.
DD: 347 ± 30 vs. 343 ± 36 ml) and total time-interval between (first)
PABD and surgery (T1 – S in 2 SCU vs. DD: 26.9 ± 2.5 vs. 25.9 ± 2.5
2003; 96; S-1–S-293 S-114
S-113
PERI-OPERATIVE BLOOD SALVAGE: THE QUALITY- each other. Mechanical processing was effective (p <0.01) in
PROBLEM OF THE LAST, INCOMPLETELY-FILLED eliminating by-products in either group. However, no differences were
LATHAM BOWL - ANALYSIS OF ELIMINATION OF BY- demonstrated concerning ER and TR both within DPS (I vs. II) and
PRODUCTS BY THE COMPLETELY AND INCOMPLETELY- CPS (III vs. IV), and between DPS and CPS (I vs. II vs. III vs. IV). ER
and TR in I, II, III, and IV of the above named parameters were as
FILLED DISCONTINUOUSLY-PROCESSING LATHAM- follows: WBC: ER: 62(12); 64(16); 74(11); 66(14). TR: 11(4); 10(4);
BOWL-SYSTEM AND THE CONTINUOUSLY-PROCESSING 8(5); 8(5). Platelets: ER: 91(10); 92(7); 88(10); 84(10). TR: 54 (69);
CHAMBER-SYSTEM 51(59); 76 (85); 84 (74). Total Protein Content: ER: 93(9); 96(5); 98(1);
98(1). TR: 1 (2); 1(0.3); 0.4(0.2); 0.4(0.1). Plasma-Hb: ER: 93(4);
AUTHORS: G. Singbartl, V. Petrovic, H. Munkel 96(3); 96(2); 95(2). TR: 315(200); 218(165); 143(63); 144(45).
AFFILIATION: AIT - ENDO-Klinik Hamburg GmbH, D-22767 Heparin: ER: 99(2); 99(1); 99(0.3); 99(0.5). TR: 0.3(0.2); 0.1(0.1);
Hamburg, Germany. 0.3(0.1); 0.3(0.2). D-Dimers: ER: 94(10); 98(2); 95(3); 93(7). TR:
1104(574); 435(207); 1948(1676); 1480(1185). F1+2: ER: 98(3); 99(1);
INTRODUCTION: Due to physical basics of mechanical processing 99(1); 99(1). TR: 28(27); 10(12); 22(12); 21(10). Elastase: ER: 95(2);
of salvaged blood, only completely-filled Latham-bowls should be 97(2); 95(7); 97(2): TR: 348(167); 280(224); 235(192); 203(197). IL-6:
processed with discontinuously-processing systems (DPS). No data ER: 99(1); 99(0.2); 99(1); 99(1). TR: 78(114); 33(66); 66(64); 59(42).
have been published comparing product quality of incompletely and DISCUSSION: Normal QW in CPS is as efficacious as BWQ in DPS
completely-filled and processed DPS (Dideco Inc., Italy) with that of
continuously- processing system (CPS) (Fresenius Transfusion GmbH, concerning ER. The reason for these unexpected results concerning
Germany). incompletely-filled DPS-bowls might be as follows: 1st administering
METHODS: Prospective lab-study of blood salvaged during infective BWQ in DPS abolished the disadvantages of incompletely-filled DPS-
surgery. In DPS (n = 10), filling, washing and emptying speed was 300 bowls; 2nd filling DPS-bowls with salvaged RBC-mass equalling to half
ml p. minute each, 5,600 RPM, 1,000ml of saline as washing solution, the volume of completely-filled DPS-bowls might have been too much
and administering the routinely used ‘better-wash-quality’ program to demonstrate differences concerning ER and TR of these systems.
(BWQ). In CPS (n = 10), the routinely used ‘quality-wash’ program
(QW) was applied; it chooses automatically the appropriate processing
parameters according to hct of salvaged blood. Following parameters
were determined before and after processing of incompletely (I) and
completely-filled (II) DPS-bowls, and corresponding RBC-equivalent
(III, IV) of CPS: Hct, WBC, platelets, total protein content, plasma-hb,
heparin, D-Dimers, F1+2, PMN-Elastase, IL-6. Elimination-rate (ER -
%) and transfusion-rate (TR - cells / substrate p. litre RBC-mass
transfused) were calculated. Statistical analysis mean(±SD) by t-/U-/H-
Test, ANOVA with Scheffe´-test; statistical significance with p<0.01
(a,b,c,d,e) with Bonferroni correction.
RESULTS: Hct of processed blood in I [0.3 (0.04) a,b,c], II [0.54 (0.03)
a,d,e
], III [0.63 (0.06) b,d] and IV [0.68 (0.04) c,e] differed (p<0.01) from
S-114
MODERN ANAESTHETIC AGENTS FOR GENERAL Remifentanil did not induce bradycardia. Hemodynamic stability was
ANAESTHESIA IN THIRD WORLD COUNTRIES best with remifentanil and methohexital.Costs for 1 hour anaethesia
with both agents is about 20 dollars.
AUTHORS: P. E. Knuepfer1, G. Heinbuch2 Data are expressed as mean ± SD
AFFILIATION: 1University Hospital Frankfurt, Mainz, Germany, Procedure duration (min) 138,2 ± 104,9
2
Hospital Zum Heiligen Geist, Frankfurt, Germany. Remifentanil (g/kg/min) 0,82 ± 0,47
Methohexital (mg/kg/h) 3,75 ± 2,13
INTRODUCTION: The vast majority of people in the Third World are Ketamine (mg/kg/h) 5,82 ± 3,11
excluded from medical treatment. One severe problem is adequate Alfentanil (mg/kg/h) 2,23 ± 1,32
general anaesthesia for surgical procedures. Anaesthetic methods are Before induction During anaesthesia
often dangererous (diethylether)1 . Perioperative mortality is 100 to 200 Blood pressure
times higher compared with western countries2. The use of remifentanil3 Systolic (mmHg) 129,8 ± 105,8 103,2 ± 25,4
in combination with methohexithal or ketamine is a possibility to Diastolic (mmHg) 76,3 ± 32,5 69,6 ± 15,1
perform safe anesthesia4. Heart rate 99,4 ± 40 89,5 ± 32,5
METHODS: In 1998 and 2001 we performed operations on 228 Surgical Procedures Performed under General Anaesthesia
patients in rural Guinea, West Africa. In 45 patients (ASA 1-3, 42,6 + Diagnosis No. of anaesthesias
years, 53,1 + 15 kg, 158,4+14,8 cm) we administered general Goitre 31
anaesthesia for surgical procedures. Atropine 0,5 mg, 0,05 mg/kg Hernia 4
midazolam and 0,5 mg/kg ketamine were given as premedication. For Utero-vaginal prolapse 5
induction 1 mg/ kg methohexital, 1 mg/kg succinycholine and 0,08 mg/ Cesarean section 1
kg vecuronium or 1mg/kg cisatracurium were administered. 27 of the Rupture of the bladder 1
patients received fentanyl (20-40 µg/kg), alfentanil (100- Hemotoma of the neck 1
200µg/kg) or sufentanil (0,5-1µg/kg) to support Tumor of the mandible 1
induction. As maintenance infusions 21 patients received a combination Analprolapse 1
of remifentanil (0,2-1,2 µg/kg/min, 20µg/ml) and REFERENCES:
methohexital (1-3/kg/h, 1mg/ml). Both anaesthetics were also applied [1] Hansen D:Anaesthesia in East Africa - Medical Inrastructure and
together in one infusion of sodium chloride. 15 patients were perioperative mortality. Anaesthesiologie und Intensivmedizin 2002,
anaesthetized with ketamine ( 2-3 mg/kg/h, 1mg/ml) and remifentanil. 7 43: 479-484
patients received alfentanil (30-60 µg/kg/h,10µg/ml). [2] Third World Anesthesia. AANA J 1994 Jun; 62 (3): 214-220
Postoperative analgesia was provided with either tramadol (1-2mg/kg) [3] H Bürkle et al.: Remifentani: a novel, short-acting, µ-opioid.
and metamizol (10-20 mg/kg). Anesthesia and Analgesia 1996; 83: 646-651
DISCUSSION: Remifentanil is appropriate to administer general [4] C Osmer, G Heinbuch: Anesthesia in third world countries. British
anaesthesia, even in technical limited settings. Additionionally Journal of Anaesthesia 1998; 81: 653-659
remifentanil was given with opioids like fentanyl, alfentanil or [5] Evans NT, et al.: Remifentanil for major abdominal surgery.
sufentanil as induction supplements, which did not prolong recovery- Anesthesia 1997; 52:606
time. The alfentanil-drip had to be reversed in 3 cases with naloxone.
Ketamine for maintaining anaesthesia produced more secretion.
2003; 96; S-1–S-293
S-115
DOES PRIOR PERCUTANEOUS TRANSLUMINAL CORONARY Data on death rate among each category were evaluated following
ANGIOPLASTY AND/OR STENT INSERTION CHANGE CARDIAC cardiac catheterization at the initial same admission. Data were
MORTALITY OF SURGERY ON FEMORAL PSEUDOANEURYSM, analyzed by chi-square probability and person's coefficient.
COMPLICATED FROM CARDIAC CATHETERIZATION RESULTS:There were significantly increased rates of death following
PTCA among secondary catheterization group compared with among
AUTHORS: M. Nakatsuka, J. Zhu primary catheterization group (P< 0.0001)
AFFILIATION: Medical College of VA, VCU Health Systems, There were more death among patients with cardiac catheterization
Richmond, VA. without PTCA than with PTCA (P< 0.0001). Patients who had stent
insertion had significantly less death rate compared with patients
INTRODUCTION: Perioperative myocardial infarction is a major without stent (P < 0.01).
cause of morbidity and mortality after non-cardiac surgery in-patients In patients who underwent repair of femoral pseudoaneurysm within 1
with coronary artery disease (CAD). week and the same admission, after cardiac catheterization, there were
Recently it was reported that patients with CAD who underwent non- no significant difference in death rate between patients with PTCA and
cardiac surgery within 90 days of PTCA had an increased adverse stent and patients without PTCT and stent.
cardiac outcome compared with non-revascularized patients (1). DISCUSSION: Patients who had cardiac catheterization with PTCA
Current ACC/AHA guideline for perioperative cardiac evaluation for and / or stent had better outcome of cardiac death compared with
non-cardiac surgery recommends that delaying surgery at least 1 week patients who simply had cardiac catheterization without PTCA and
after PTCA and if a coronary stent is used, delaying surgery of at least 2 stent. No significant differences in death rate with repair of femoral
weeks and ideally 4 to 6 weeks before non-cardiac surgery. pseudoaneurysm done within 1 week after cardiac catheterization
However, some patients with CAD returned to operating room due to between in-patients without PTCA and stent and in-patients with PTCA
complication of cardiac catheterization with complication of femoral and stent.
pseudoaneurysm within several days. It seems reasonable not to delay repair of femoral pseudoaneurysm
We reviewed the incidence of cardiac death following anesthesia and which develop as a complication of cardiac catheterization whether
surgery for femoral pseudoaneurysm after cardiac catheterization with PTCA with stent or without PTCA since expanding nature of
PTCA and / or stent within 1 week at the same admission. pseudoaneurysm.
METHODS: We reviewed entire cardiac catheterization data at our REFERENCES:
university hospital from 1992 to 2002. Posner ET AL:Anesth Analg. 1999; 89:553-68.
Patients were categorized into two groups. (1) primary cardiac
Number of
catheterization group whose primary reason of admission was to have Cardiac Catheterization Number
Deaths
P-Value
cardiac catheterization and (2) secondary cardiac catheterization group 1(A) PTCA among primary cath 5726 39
who required cardiac consultation after admission and subsequently <0.0001
(B) PTCA among secondary cath 853 61
underwent cardiac catheterization. 2(A) with PTCA 6579 92
Surgery for pseudoaneurysm of femoral artery following cardiac <0.001
(B) without PTCA 14790 327
catheterization within 1 week at the same admission were divided into 2 3(A) with Stent 3043 43
<0.01
groups (B) without Stent 17826 376
(A) Cardiac catheterization without PTCA and Stent 4 Surgery on Femoral Pseudoaneurysm
133 5
(B) Cardiac catheterization with PTCA and Stent. (A) Cardiac Cath without PTCA and Stent 0.59
46 1
(B)Cardiac Cath with PTCA and Stent
Equipment/Monitoring
Equipment/Monitoring
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S-116
SECURE ACCESS TO ANESTHESIA RECORDS AND time status monitor of operative stage and patient location. Staff in the
OPERATING ROOM SCHEDULES USING AN INTERNET waiting area use the system to keep patients and relatives informed. It is
BROWSER used extensively in the billing and denials offices and it forms the basis
of a QA cycle that enables the review of QA events recorded in the
AUTHORS: I. C. Sanderson, W. Gilbert, J. Valles AIMS, feeding-back recommendations by email to the providers
AFFILIATION: Department of Anesthesiology Duke University involved. A popular feature of the system is a page of secure
Medical Center, Durham, NC. personalized views of data, including a summary of all cases, QI
incidents and schedules. The system has the potential for use in remote,
INTRODUCTION: Duke University Hospital has used Anesthesia real-time consultation of ongoing anesthetics from any location using a
Information Management Systems (AIMS) to document over 300,000 web-browser.
anesthesia records. However, until now the only means of accessing DISCUSSION: The secure availability of anesthesia records and
past patient records has required accessing a custom point-of-care derivatives of AIMS data over the Internet has led to a surge of use of
workstation, which is not optimal for planning clinical care, QA or this information in our institution. This type of access has already
administrative use in highly distributed hospital systems. Providers impacted positively upon patient care and on our hospital’s operational
often had no knowledge of a patient’s past anesthesia history even efficiency.
though it had been recorded using the AIMS. Clinical staff often plan
patient care with other anesthesia providers outside the operating room
suite, sites for which an AIMS client installation would be expensive
and difficult to maintain.
METHODS: We have implemented an extension to our AIMS which
enables secure access to patient anesthesia records and other derived
information in near-real time over the Internet. Our system consists of
web-applications that access the database of our AIMS. The client
application is any web-browser and the response is a dynamic HTML
page showing the anesthesia record over the Internet. The system
addresses security concerns using 128 bit Secure Socket encryption,
user authentication and audit to prevent inappropriate access. It also
fully supports an Application Service Provider model where one central
server can provide the anesthesia records for multiple hospitals.
RESULTS: In 10 months the system has generated a user base of over
200 and an average of 750 requests/day. It is used extensively for
looking up personal anesthesia schedules, past anesthesia histories and
current cases. A typical usage pattern is for providers to review their
schedule of cases from home and examine past anesthesia histories and
cases. A derivative of the system provides a Big Board view of the
whole operating room suite displayed on 5 flat-panels. As data updates,
the display refreshes automatically every minute to provide a near-real
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THE USE OF AN INTERNET-BASED PHARMACY BILLING RESULTS: SAS has allowed the abolition of the cassette system for
SYSTEM WITH AN AUTOMATED ANESTHESIA RECORD dispensing drugs and fluids, except controlled substances, which are
still centrally managed using a much simplified system. The pharmacy
AUTHORS: I. C. Sanderson, J. Valles, R. Cory, L. Hollowell, L. maintains stocked carts in the operating rooms, and anesthesia staff
Alexander have convenient access to a wider range of drugs.
AFFILIATION: Department of Anesthesiology Duke University DISCUSSION: The use of a thin Internet client with an underlying
Medical Center, Durham, NC. web-application architecture for the SAS has advantages in a complex
and geographically distributed billing environment. The remote billing
INTRODUCTION: Charging for anesthesia drugs is a complex office only has to open up an Internet Browser to process anesthesia
process involving manual data entry before the patient or insurance pharmacy charges. A second phase is planned in which the web-
company is properly billed. Anesthesia Information Management application will generate XML as well as HTML output. This will
Systems (AIMS) have claimed the automation of pharmacy billing as a enable a completely automated charging solution with no intervening
benefit. In theory the best solution is direct data transfer from a point- manual steps except audit and review. With automated and more
of-care recording device to a pharmacy billing system using an HL7 accurate pharmacy billing, we will continue to reengineer drug
interface, but in practice this has rarely been achieved. Numerous distribution systems to minimize waste, focus on medication safety and
obstacles lie in the way, the most significant being data entry artifact realize significant cost savings.
and the custom of anesthesia providers to document administered drugs
without regard for vial size and wastage.
At Duke University Hospital we have a large AIMS installation
(Draeger Inc, Telford, PA) with over 150 workstations and 200 users in
3 hospitals covering the perioperative process. Our original drug billing
procedure was heavily manual, with pharmacy staff documenting drug
usage from cassettes issued to providers for each case. An audit of 15
cases revealed inaccuracies in patient charges compared to the drugs
documented in the AIMS, with underbilling of over $100 in 20% cases.
Our new Internet-based system uses AIMS data to summarize
pharmacy charges, allowing non-controlled drugs to be dispensed from
open carts in the operating rooms and stocked by pharmacy.
METHODS: Our solution relies on the premise that pharmacy charges
should originate from AIMS documentation at the point-of care. Billing
codes have been determined statistically and financially to incorporate
wastage. The tool is a dynamic, Internet-based pharmacy report called
Saturn Agent Summary (SAS). The SAS is generated using a middle-
tier Java web-application accessing the AIMS database. Pharmacy staff
at a remote location can review the SAS for each case using an Internet
Browser. Privacy concerns are addressed by the use of data encryption,
user authentication and user audit.
2003; 96; S-1–S-293 S-119
S-118
HUMIDITY IN ANESTHESIA BREATHING SYSTEMS
AUTHORS: J. G. Brock-Utne
AFFILIATION: Stanford University, Stanford, CA.
INTRODUCTION: A preliminary study done in 1981 suggests that
the Mapelson D (Bain system) offers higher humidity in the system
compared to most other systems, even the semi-closed circle absorber
system. [1] This has not, as far as we are aware, been substantiated. The
object of this study was to compare the absorber system to the Bain
system using the Narcomed2B (North American Draeger, Telford., PA
18969) anesthesia machine for both systems.
METHODS: Twenty-four patients ASA 1 and 2, between the ages of
36 and 55, scheduled for non-thoracic surgical procedures under general
anesthesia were enrolled after written informed consent had been
obtained. The study was approved by the University Panel on Human
Subjects in Medical Research. General anesthesia was induced and the
trachea intubated in routine fashion. Anesthesia was maintained with
N2O and oxygen 30% with isoflurane 05-1%. Fresh gas flow was kept
at 2L/min with the absorber system (A) and 70ml/kg with the Bain (B).
Relative humidity and absolute humidity of the airway gases were
measured with a humidity sensor (Gibeck, Indianapolis, IN 46236).
Fifteen minutes of baseline measurements were done prior to randomly
studying each breathing system in the same patient. Results were
expressed as mean (SD) or median (interquartile range), and analyzed
by a paired T-test or Wilcoxon Signed Rank test. P<0.05 was considered
significant.
RESULTS: The results for relative humidity (median and interquartile
range) were A=96.3 (6.3) and B=96.1 (7.9). The results for absolute
humidity (mean and interquartile range) were A=34.1 (2.3) and B=34.6
(2.6).
SUMMARY: In this clinical study we did not find any difference in
relative or absolute humidity between the absorber system and the Bain
system. The importance of these results is the subject of further studies.
REFERENCE:
1. Flynn PJ, Morris LE. Humidity in anaesthetic systems. Br J Anaesth,
1981; 53: 1096.
S-119
NOVEL BENCH VALIDATION OF A NEW, FAST-RESPONSE and the measured wet and dry T from the humidity sensor.
AIRWAY SENSOR OF HUMIDITY AND TEMPERATURE RESULTS: Over the clinical range of delivered T (20-40ºC) and RH
(0-100%) in 6 different experiments (20 measurements/experiment),
AUTHORS: A. Rosenbaum1, W. Y. Wu1, L. W. Parker2, B. J. Ages2, J. correlation of measured RH by the humidity sensor versus the value
C. Milliken2, P. H. Breen1 from the thermohygrometer were excellent (R2=0.972±0.023,
AFFILIATION: 1Dept of Anesthesiology, University of California- slope=0.975±0.061 and Y-intercept=0.435±1.005).
Irvine, Orange, CA, 2Division of Cardio-Thoracic Surgery, University DISCUSSION: The HS provides highly accurate airway measurements
of California-Irvine, Orange, CA. over a wide range of gas T and humidity. The accuracy of the HS,
together with its fast response, will support the ability to measure VO2
INTRODUCTION: Measurement of pulmonary O2 uptake (VO2) (and VCO2) during anesthesia, and help introduce non-invasive
should help detect metabolic derangement during anesthesia and non- detection of metabolic derangement during anesthesia and non-steady
steady state critical events. Due to non-steady state conditions, use of state critical events (1).
N2O, presence of high inspired O2, and difficulty to measure mixed REFERENCES:
expired oxygen fractions during anesthesia, VO2 must be measured by 1. Ann Biomed Eng 28:1159-1164; 2000.
VI . FIO2-VE FEO2, where V and FO2 are gas volumes and oxygen 2. U.S. Patent Number 6,014,890; 2000. Support by NIH R01 HL-
fractions in inspiration and expiration (1). The higher temperature (T) 42637.
and humidity of expired gas (relative to inspired gas) must be measured
or the error in VO2 can reach 50% during O2 breathing (1)! Accordingly,
we have developed a fast response airway opening humidity sensor
(HS) (2), which incorporates dry and wet tiny thermocouples. Humidity
is measured by psychrometry, where dry gas causes evaporative cooling
to decrease wet T below dry T. Psychrometric principles require a
threshold gas velocity to measure humidity (5 L/min for the dimensions
of our HS). Accordingly, we designed a special dynamic bench set-up to
test and validate the HS over a wide range of gas T and humidity.
METHODS: In a circular circuit (Figure), a coil of copper tubing (1.1
mm ID) was placed in a T-controlled water bath and connected through
vinyl tubing (1.7 cm ID) to the HS, the thermohygrometer, to a parallel
circuit that allowed controlled gas flow through a water desiccant (8
mesh CaSO4) chamber, and to an occlusive roller pump (5 L/min). The
copper tubing allowed rapid heat transfer from the water bath to control
T of gas delivered to the humidity sensor. Metered volumes of water
were injected into the copper tubing to increase gas humidity, while the
water desiccating circuit was adjusted to remove humidity. The
psychrometry equation was solved for the psychrometry coefficient, A,
knowing relative humidity (RH) measured by the thermohygrometer
S-121 2003; 96; S-1–S-293
S-120
CAN AIRWAY HUMIDITY SENSOR THERMOCOUPLES BE performed in a precision T-controlled water bath.
CALIBRATED IN TEMPERATURE-CONTROLLED WATER RESULTS: Over the T range of 0 to 40 ºC, linear regression of
BATHS? thermocouple T versus air chamber T was excellent (R2=0.9998,
slope=1.05, y-intercept=-0.82). Because measured inner gas chamber
AUTHORS: A. Rosenbaum1, W. Y. Wu1, L. W. Parker2, B. J. Ages2, J. RH was always 100%, measured wet and dry T were equal (no
C. Milliken2, P. H. Breen1 evaporation from wet thermocouple to decrease its T).
AFFILIATION: 1Dept of Anesthesiology, University of California- DISCUSSION: We conclude that calibration of thermocouples in T-
Irvine, Orange, CA, 2Division of Cardio-Thoracic Surgery, University controlled water baths is identical to, and much easier than, calibration
of California-Irvine, Orange, CA. in the gas phase. Accordingly, HS measurements of airway gas T and
humidity are reliable. Airway humidity and T measurement allows
INTRODUCTION: Pulmonary O2 uptake (VO2) is given by VI . FIO2- accurate determination of VO2 (and VCO2) during anesthesia, and helps
VE . FEO2, where V and FO2 are gas flows and oxygen fractions in support, we believe, future non-invasive detection of changes in
metabolism and critical events during surgery (1).
inspiration and expiration. The higher temperature (T) and humidity of REFERENCES:
expired gas (relative to inspired gas) must be measured or the error in 1. Ann Biomed Eng 28:1159-1164; 2000.
VO2 can reach 50% during O2 breathing (1)! Accordingly, we have
2. U.S. Patent Number 6,014,890; 2000.
developed a fast response airway opening humidity sensor (HS) (2), 3. Fundamentals of Physics, John Wiley & Son, 1997; pp 475.
which incorporates dry and wet tiny thermocouples. Humidity is
measured by psychrometry, where dry gas causes evaporative cooling to Support by NIH R01 HL-42637.
decrease wet T below dry T. Calibration of thermocouples in gas is
problematic because constant and adjustable gas T is difficult, thermal
conductivity of air is 23 times less than that of water (3), and gas must
be saturated to avoid evaporative cooling. In this study, we develop an
apparatus and hypothesize that thermocouple calibration in hot and cold
water baths is identical to the measurements in the gas phase.
METHODS: We constructed a double-walled chamber by gluing a
small beaker (1.2 L) onto the inner bottom of a larger beaker (8 L).
From an elevated supply reservoir (20 L), water flowed (730 ml/min)
and circulated through the outer chamber to provide a water jacket
around the inner closed gas chamber (Figure). Baseline supply reservoir
water temperature was about 40ºC. Then, ice was added to the supply
reservoir to generate 8 water T levels down to 5ºC, measured by
precision mercury bulb thermometer. A small amount of water (< 1 ml)
was placed in the inner gas chamber in order to maintain 100% RH. The
HS and a precision thermohygrometer (Oakton WD-35612-00, Vernon
Hills, IL), were placed inside the inner chamber. Prior to a trial, a two-
point calibration of the HS, spanning the measurement range, was
S-121
ROLE OF HEATED AND HUMIDIFIED INTRAPERITONEAL Furthermore, no differences were observed on the quality of recovery
GASES DURING LAPAROSCOPIC ROUX-EN-Y SURGERY - throughout the postoperative period.
EFFECT ON CORE TEMPERATURE AND POSTOPERATIVE CONCLUSIONS: The Insuflow device may be a useful alternative to
PAIN other active warming devices (e.g., forced air warming) for maintaining
temperature during laparoscopic surgery. These preliminary findings
AUTHORS: M. A. Hamza, A. Recart, P. White, B. Schneider, B. suggest that the device may also be associated with lower pain scores in
Ogunnaike the early postoperative period and shorter recovery times. However,
AFFILIATION: Departments of Anesthesiology, Pain Management further studies are needed comparing this device to other active
warming devices.
and Surgery University of Texas Southwestern Medical Center, Dallas, REFERENCES:
TX. 1. Luck AJ, Moyes D, Maddem GJ, Hewett PJ. Core temperature
INTRODUCTION: Intraoperative hypothermia occurs commonly changes during open and laparoscopic colorectal surgery. Surg Endosc
1999;13:480-3.
during major laparoscopic procedures.1 Controversy exists regarding 2. Ott DE, Reich M, Love B, et al. Reduction of laparoscopic-induced
the efficacy of heated and humidified intraperitoneal gases in hypothermia, postoperative pain and recovery room length of stay by
maintaining core body temperature.2,3 Therefore, we designed a sham- pre-conditioning gas with the Insuflow® device: A prospective
controlled study to evaluate the effect of the Insuflow® device on randomized controlled multi-center study. JSLS 1998;2:321-329.
perioperative body temperatures and postoperative analgesic 3. Nguyen NT, Furdui G, Flemming NW, et al. Effect of heated and
requirements. humidified carbon dioxide gas on core temperature and postoperative
METHODS: 18 morbid obese patients undergoing laparoscopic Roux- pain. Surg Endosc 2000;16:1050-1054.
en-Y procedures under a standardized general anesthetic technique
were randomly assigned to either a control (Sham) group receiving an SHAM (n=10)
INSU-
SHAM (n=10)
INSU-
‘inactive’ Insuflow device, or an active treatment (Insuflow) group FLOW(n=8) FLOW(n=8)
First pain
receiving warmed and humidified intraperitoneal gases. Esophageal Age (yr) 42±16 48±7 49±25 53±35
rescue (min)
(core) temperature was measured intraoperatively and tympanic Weight (kg) 124±18 114±16
PACU stay
134±92 98±31
membrane temperature was measured postoperatively. No other active (min)
Pain score
warming devices were used during surgery. Verbal pain scores (0=none Gender (M/F) 1/9 0/8 5 (0-8) 2.5 (0-8)
PACU (0-10)
to 10=maximal) were recorded in the postoperative period. In addition, Surgery time
100±27 109±24
Morphine in
14±8 11±11
the postoperative opioid analgesic requirement and quality of recovery (min) PACU (mg)
Insuflation Pain score at 24
(0-18) were recorded on the day of surgery, as well as postoperative 222±77 200±96 5 (1-10) 4 (0-6)
volume (L) hr (0-10)
days 1(POD 1), 2 (POD 2) and 3 (POD 3). Temperature @
PCA morphine
RESULTS: Use of the active Insuflow device was associated with start of surgery 36.2±0.4 36.1±0.5 33±11 22±15
< 24 hr (mg)
(C)
higher intraoperative temperatures. Although pain scores were lower in Quality of
Temperature @
the early postoperative period (i.e. PACU), there were no significant 90 min (C)
35.3±0.1 35.7±0.7 recovery score 12±3 12±3
differences in the opioid analgesic requirements after surgery. The at 24h (n)
Temperature @
lengths of PACU and hospital stays were shorter in the Insuflow group Total hospital
end of 35±0.2 35.4±0.2 stay (hr) 66±9 56±6
(98±31 vs 134±92 min and 56±6 vs 66±9 h, respectively). No patients surgery (C)
developed severe intraoperative hypothermia in either group.
2003; 96; S-1–S-293 S-123
S-122
DIFFERENCES IN TYMPANIC AND RECTAL greater mean temperature drop was seen in the rectum over the
TEMPERATURE CHANGES AFTER MRI OF THE BRAIN IN tympanic membrane. Potential reasons may have been due to uneven
CHILDREN AFTER GENERAL ANESTHESIA absorption of radiofrequency radiation within the body resulting in local
heating of the head or a lag in the temperature measured in the rectum.
AUTHORS: Y. Bryan, O. Gottlieb, T. Templeton, D. Coalson Further studies of temperature monitoring during MRI scanning are
AFFILIATION: University of Chicago, Chicago, IL. needed in order to understand the changes in temperature occurring at
different body sites.
INTRODUCTION: Using clinical temperature monitoring equipment REFERENCES:
is incompatible in the MRI due to the strong magnetic field and 1.J Microwave Power 1987;2:94
therefore specialized fluoroptic systems are required. (1) The 2.J Magn Reson Imaging 2000;12:30-36
introduction of radiofrequency radiation is known to be thermogenic 3.AJNR 1988;2:287
and causes tissue heating. (2) Adults undergoing MRI of the head .
experienced increases in their forehead skin temperatures. (3) We
thought to determine if there was a difference in the core body
temperature changes between the rectum and tympanic membrane in
children that underwent MRI of the brain.
METHODS: With IRB approval, we prospectively studied 17 children
who underwent MRI of the brain without contrast under general
anesthesia. The ages ranged from 19 months to 13 years and weights
from 10.8 to 77 kg. The induction and emergence occurred in a room
adjacent to the MRI were the ambient temperature ranged from 22-24
C. 16 were induced with sevoflurane with LMA placement. One patient
received propofol and mivacurium for induction and was intubated.
Maintenance was with sevoflurane with patients breathing
spontaneously.The children were covered with a hospital gown and
cotton blanket; no other heating device was used. Rectal and tympanic
temperatures were measured immediately after induction prior to MRI
and after MRI prior to emergence from general anesthesia.
RESULTS: The mean difference in pre and post-scan rectal
temperature was -1.1 +/- 0.3 C while the mean difference in pre and
post-scan tympanic temperature was - 0.52 +/- 0.5 C. The mean rectal
temperature was 37.2 +/- 0.3 C before MRI and 36.0 +/- 0.3 C after the
MRI. The mean tympanic temperature was 36.7 +/- 0.4 before the MRI
and 36.2 +/- 0.3 C after the MRI. The mean times between pre to post-
scan rectal and tympanic temperature measurements were similar.
DISCUSSION: Our study indicates that there was a difference in the
mean core body temperature change measured at two different sites. A
S-123
CARBON DIOXIDE LEVELS IN THE OPERATING ROOM DISCUSSION: Moderately elevated levels of CO2 are well tolerated.
DURING GYNECOLOGICAL LAPAROSCOPIC SURGERY CO2 levels increased during laparoscopic surgery, but the mean
concentration was below 1000 ppm for both operating rooms. But in
AUTHORS: H. Ryu1, D. Kim2, K. Seo3, W. Ahn1 many cases, the high levels of CO2 were above 1000 ppm. The
AFFILIATION: 1Department of Anesthesiology and Pain American Society of Heating, Refrigerating and Air-Conditioning
Management, College of Medicine, Seoul National University, Seoul, Engineers, Inc. (ASHRAE) guideline for indoor air CO2 is less than 650
Republic of Korea, 2Department of Statistics, Sungkyunkwan ppm above outdoors, about 950 - 1000 ppm, and the US Building
University, Seoul, Republic of Korea, 3Department of Anesthesiology, Owners and Managers Association (BOMA) recommends indoor CO2
Kimchun Cheil Hospital, Kimchun, Republic of Korea. levels less than 800 ppm. One more thing of note is that the volume of
the operating room seems to be more important than the air exchange
INTRODUCTION: Carbon dioxide (CO2) is used in laparoscopic rate. We suggest that laparoscopic surgeries using CO2 should be
surgery to insufflate the abdominal cavity for a better view and access performed in large well-ventilated rooms and guidelines for CO2 levels
of the operating field. There seems to be a tendency for in operating rooms should be proposed. The effect of moderately
anesthesiologists to be somewhat more drowsy and less focused during elevated CO2 on the ability of the surgeon and the anesthesiologist to
laparoscopic surgery. Factors that may contribute to this tendency
include relatively dark operating room, relatively stable patient‘s focus on their jobs requires further evaluation.
conditions associated with surgery and the possibility of high CO2
levels. This study evaluated the CO2 level in two operating rooms
during gynecological laparoscopic surgery.
METHODS: CO2 level was checked using a portable gas detector, Q
check (TSI Inc., USA), during 15 and 17 cases of laparoscopic surgery
in two different operating rooms, A and P. The detecting bar was placed
between two IV poles used for tenting aseptic drapes. Mean, high, and
low levels of CO2, and the number of persons in the operating room
were checked during the first 15 minutes of anesthesia, each 15minutes
after CO2 insufflation until CO2 insufflation was stopped, the first
15minutes immediately after the cessation of CO2, and the 15 minutes
after the end of surgery. Air change rates and room dimension of both
operating rooms were also measured.
RESULTS: There was a significant increase in mean CO2 level in room
P compared to room A (p = 0.0002), but the average difference was 137
ppm. Mean CO2 levels in room P was under 1000 ppm except in one
case in which it rose up to 2200 ppm, whereas in room A, all mean CO2
levels were less than 800 ppm. Air exchange rate and room dimension
for room A were 16.4 / hr and 113.2 m3, while for room P, they were 19
/ hr and 63.5 m3 respectively.
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UNPREDICTABLE POTASSIUM CHANGES IN DONATED levels demonstrated wide variability (see figure). The serum potassium
BLOOD FOLLOWING WARMING levels of the recipients before blood administration (3.7 +/- 0.7 meq/l)
were similar to levels after transfusion (3.8 +/- 0.7 meq/l), with much
AUTHORS: M. B. Robinson, S. Sastry, H. J. Lemmens, J. J. Brock- smaller variability. Interestingly, there was no significant relationship
Utne between any of the measured potassium levels and storage duration of
AFFILIATION: Stanford Hospital, Palo Alto, CA. the blood.
INTRODUCTION: Common clinical practice for administering
donated packed red blood cells uses countercurrent warming to prevent
hypothermia. The maximum temperature for warming is currently 42
degrees since blood will hemolyze at a rate of 2.26 mg Hgb/ 100cc/min
when heated to 50 degrees, but blood warmed in a water bath does not
have significant hemolysis below 40 degrees (1). No published data
demonstrate if there is clinically significant hemolysis using current
standard practices with countercurrent warming devices set to 42
degrees. Since a rise in potassium has been shown to be a sensitive
indicator of as little as 1% of hemolysis (2), we measured the potassium
of donated blood before and after warming through a countercurrent
device. Since hyperkalemia could also be of concern, recipient
potassium levels were also studied.
METHODS: Potassium levels from 12 donated packed red blood cell
units were measured both before and after warming using Hotline
countercurrent heat exchange (SIMS Level 1, Rockland, MA) at modest
flow rates. Units were handled in the usual clinical practice, each kept
in a cooler bucket until use, then allowed to drain by gravity through a DISCUSSION: The results above indicate that potassium levels on
Hotline device, with average flow rates of 80 ml/min and outlet average are unchanged after heating though a Hotline. However, in
temperature of 34.8 degrees Celsius. Simultaneous samples were drawn individual units an unpredictable increase or decrease may be observed.
immediately before and after the large bore warmer tubing for analysis. It is not clear if these changes are a result of warming or simply reflect a
Recipient arterial blood gases were measured immediately before and very heterogeneous potassium distribution in a unit of packed red blood
again 3-5 minutes after transfusion of the heated red blood cells. cells.
Medications known to alter potassium were avoided. All data are REFERENCES:
expressed as a mean +/- standard deviation. A paired t test was used for 1. British Journal of Anaesthesiology. 1974;46:742-746.
group comparisons, and relationships between potassium levels and 2. Journal of Trauma. 1992;33:89-94.
blood unit storage duration were examined using regression analysis.
RESULTS: Average potassium values measured in the packed red
blood cell units before warming (18.6 +/- 7.8 meq/l) were not different
from the values after warming (18.5 +/- 6.3 meq/l); both potassium
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EFFECT OF INCREASED INTRA-ABDOMINAL PRESSURE larger production of toxic metabolites compared to isoflurane.
ON LIVER FUNCTIONS DURING LAPAROSCOPIC Persistence in elevated -GT to the 7th postoperative day with halothane
CHOLECYSTECTOMY IN PATIENTS ANESTHETIZED WITH may be due to the generalized microsomal enzyme induction. On the
HALOTHANE VERSUS ISOFLURANE other hand, isoflurane facilitates oxygen delivery to the liver by
preserving hepatic arterial blood flow.[2]
AUTHORS: G. El-Fandy, A. El-Hadidy CONCLUSION:
AFFILIATION: Theodor Bilharz Research Institute, Cairo, Egypt. Laparoscopic cholecystectomy had better be avoided in compromised
liver functions and, if necessary, halothane should be substituted by
INTRODUCTION: The present study aims to evaluate the effects of isoflurane.
increased intra-abdominal pressure on liver functions during REFERENCES:
laparoscopic cholecystectomy compared to open cholecystectomy 1. Ann. Surg. 1994, 219 : 362-6
under halothane and isoflurane anesthesia. 2. Anesth. Analg. 1984, 63 : 557-565
METHODS: A total of 60 patients scheduled for cholecystectomy in 2
groups of 30 patients each, further subdivided into equal subgroups:
Subgroup [A] receiving halothane (0.2-0.4%) and subgroup [B]
receiving isoflurane (0.2-0.3%): Group (I) patients underwent
conventional open surgical cholecystectomy. Group (II) patients were
submitted to laparoscopic excision of the gall bladder. Anesthesia was
maintained throughout with nitrous oxide in oxygen (1:1) and
incremental doses of fentanyl and vecuronium. Peripheral venous blood
samples were obtained preoperatively, immediately postoperatively and
at 24 hours, then at 5 and 7 days postoperatively. Liver functions (total
bilirubin, serum albumin, AST, ALT, -GT and ALP) were assessed.
RESULTS: A statistically significant increase in liver enzymes was
reported in Group (I) only after halothane anesthesia and returned to
normal within 7 days postoperatively. A similar increase was detected
in both subgroups of Group (II) which lasted for 5 postoperative days
with isoflurane and 7 days with halothane.
DISCUSSION: Laparoscopic cholecystectomy is a widely accepted
alternative to laparotomy because of its limited surgical invasiveness
and shorter hospital stay.[1] However, high intra-abdominal pressure
over an extended period of time may be associated with detrimental
impairment of liver functions. This may be due to disturbances in
hepatic perfusion but may also be due to manipulations of the liver and
neurohumoral mediated response to surgical stress. Another possible
factor may be the ischemic reperfusion injury after deflation. Halothane
produces a more sustained increase in liver enzymes because of the
2003; 96; S-1–S-293 S-127
S-126
PHARMACOKINETIC SIMULATION EXPLAINS THE concentration level 3.6-fold, 4.4-fold, and 5.1-fold as high as the target
MEASURED PROPOFOL CONCENTRATION RISING concentration, respectively. Under all conditions blood propofol
HIGHER THAN THE PREDICTED VALUE concentration showed a sharp decline near to the target concentration
after reaching the maximal level, and reached to a plateau at a level
AUTHORS: O. Nagata, T. Igarashi, H. Iwakiri, M. Ozaki higher than the target concentration.
AFFILIATION: Tokyo Women's Medical University, Tokyo, Japan. DISCUSSION: The analysis by simulation using findings from the
DDT gave us explanation for a large difference between the target blood
INTRODUCTION: It is said that the target-controlled infusion (TCI) concentration and measured blood concentration with a basic
pump has not been approved for clinical use in the USA as the FDA has mechanism that decreased cardiac function leads to prolonged
a concern about accuracy of the TCI system because there was a case circulation time. In our simulation, the concentration profile of
where the measured blood propofol concentration was about 4-fold intravenously administered drug was analyzed using dye-dilution
higher than the predicted concentration in a patient with deteriorated curves available from dye dilution method on the basis of several
cardiac function. It is widely known that errors are caused in assumptions. Accordingly, there is a possibility that the concentration
pharmacokinetic approach such as pharmacokinetic model because of ratio between the maximal level and concentration after uniform
inter-individual variability and intra-individual variability. However, diffusion of the drug is different between dye and propofol, suggesting
there have been few investigations conducted on the conditions that fit likely differences between the simulation results and the measured
well to pharmacokinetic model, which is based on an assumption that concentration of propofol.
drug is diffused uniformly in compartments. Thus, we conducted an
analysis by simulating propofol circulation in the body, and uniform
diffusion in the blood (compartment) after administration into the blood
vessel, with an aim to examine differences between the measured
concentration and blood concentration predicted by the compartment
model.
METHODS: Since pharmacokinetics of propofol follow 3-
compartment model, change in blood propofol concentration p(t) after a
single dose can be expressed by sum of 3 exponential functions. We
defined the dose m(t) of propofol at each time point during TCI
administration at interval of 1 second through simulation, assuming that
the target propofol concentration was 3 g/mL. Because the parameters
in dye-dilution technique (DDT) have correlation with a cardiac index,
we defined three dye-concentration functions f1(t), f2(t), and f3(t) for
three cardiac conditions. With these functions, we analyzed the
predicted propofol concentration Cpredit (t), and propofol concentration
in the peripheral tissue Ctransit (t) by simulation.
RESULTS: In models with normal cardiac output, low cardiac output,
and extremely small cardiac output, the maximal blood concentrations
appeared around 19 seconds, 23 seconds, and 33 seconds with
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EFFECT OF AEP MONITORING ON INTRAOPERATIVE the time required to achieve an Aldrete PACU discharge score of 10 and
DRUG USAGE AND RECOVERY AFTER INPATIENT the length of recovery room stay were both significantly reduced in the
SURGICAL PROCEDURES: A CLINICAL UTILITY STUDY AEP monitored group (P<0.05). There was no difference between the
two groups in postoperative side effects or complications.
AUTHORS: A. Recart, I. Gasanova, P. F. White, A. Wang, S. Jones CONCLUSIONS: Use of the AEP monitor during general anesthesia
AFFILIATION: Department of Anesthesiology and Pain Management reduced the anesthetic and analgesic requirements, as well as the length
University of Texas Southwestern Medical Center, Dallas, TX. of the PACU stay. This clinical utility study suggests that AEP
monitoring may be useful in facilitating the recovery process after
INTRODUCTION: The auditory evoked potential (AEP) monitor has inpatient surgical procedures.
been recently introduced as a more “physiologic” approach to
monitoring the central nervous system effects of anesthetic drugs. The
AEP monitor provides an EEG-derived index (AAI) in response to an STANDARD PRACTICE AEP MONITORED
auditory stimulus. This study was designed to determine if the (n=29) (n=31)
availability of information on the AAI value during surgery would Age (yr) 43±14 44±15
influence the administration of anesthetic and analgesic drugs, and
improve the recovery profile after inpatient surgical procedures. Weight (kg) 110±47 94±50
METHODS: 60 consenting inpatients undergoing elective general Surgery time(min) 113±47 103±41
surgery procedures were randomly assigned to one of two study groups: Fentanyl (mcg) 400±158 270±120*
(1) Standard Practice or (2) AEP Monitored. Although the AEP monitor
was connected to all patients, the information on the AAI was only Desflurane (ET%) 4.9±0.8 3.7±0.6*
made available during the procedure to anesthesiologists assigned to the Extubation (min) 10±6 7±5
AEP Monitored group. All patients received midazolam, 1-2 mg IV, for FT score>12 (min) 54±32 29±19*
premedication. Anesthesia was induced with propofol, 1.5-2 mg/kg, and
fentanyl, 50-100 µg, followed by variable concentrations of desflurane, Aldrete score>10 (min) 100±52 60±31*
3-6% ET, and intermittent boluses of fentanyl, 50g IV, for maintenance PACU stay (min) 106±49 78±31*
of anesthesia. In the AEP Monitored group, the inspired desflurane *P < 0.05 vs Standard Practice group
concentration was titrated to maintain an AAI value of 15-25. In the
Standard Practice group, the inspired desflurane concentration was
varied based on standard clinical signs. The recovery times to achieve a
fast-track (FT) score >12 and an Aldrete score of 10, as well as PACU
stay, were recorded. Data was analized using ANOVA and x2 with
p<0.05 considered statistically significant. Patient satisfaction was
recorded on a 100-point verbal analog score.
RESULTS: Use of the AEP monitor reduced desflurane consumption
by 25% compared to the Standard Practice group (P<0.01). In addition,
the AEP Monitored group received less intraoperative fentanyl and
more rapidly achieved FT eligibility after anesthesia (P<0.05). Finally,
S-129 2003; 96; S-1–S-293
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IS THE BISPECTRAL INDEX USEFUL IN PREDICTING CONCLUSIONS: Although the peak increase in the BIS value after
SEIZURE TIME AND AWAKENING AFTER ECT correlated with the duration of EEG activity, the BIS values at
ELECTROCONVULSIVE THERAPY? awakening varied widely among patients. These data suggests that BIS
values on awakening following ECT reflects the residual effects of
AUTHORS: A. Recart1, S. Rawal1, P. White1, L. Stool1, L. Thornton2 methohexital, as well as post-ictal depression.
AFFILIATION: 1Department of Anesthesiology and Pain
Management University of Texas Southwestern Medical Center, Dallas, Factors studied Correlation coefficient P-value
TX, 2Department of Psychiatry University of Texas Southwestern Baseline BIS Age -0.25 0.1
Medical Center, Dallas, TX. Baseline BIS Depression Score -0.1 0.3
INTRODUCTION: The EEG bispectral index (BIS) measures the Pre ECT BIS Peak Post ECT BIS 0.4 <0.01
hypnotic component of the anesthetic state and is alleged to be useful in
Pre ECT BIS Awakening time 0.5 0.01
predicting awakening from general anesthesia. This study was designed
to evaluate the changes in BIS values during and after electroconvulsive Pre ECT BIS EEG Seizure 0.38 <0.01
therapy (ECT) under methohexital anesthesia. We hypothesized that the Pre ECT BIS Motor Seizure 0.34 <0.01
BIS would be useful in predicting ECT-induced seizure times and
awakening after ECT. EEG Seizure Post ECT peak 0.39 0.01
METHODS: 25 consenting patients with major depressive disorders Post ECT supres-
receiving a total of 100 maintenance ECT treatments participated in this EEG Seizure -0.05 0.1
sion
prospective study. Al patients were premedicated with glycopyrrolate,
0.2 mg IV, and anesthesia was induced with methohexital, 0.75-1.25 mg EEG Seizure Eye opening time 0.29 <0.01
kg-1 IV. The EEG-BIS was monitored continuously throughout the ECT
procedure and BIS values recorded at specific endpoints including pre-
anesthetic (baseline), after induction of anesthesia (pre-ECT), end-ECT
(peak), post-ECT (minimum), and upon awakening (eye opening). The
durations of motor and EEG seizure activity were correlated with the
seizure duration and the maximal increase in the BIS during the ECT
procedure.
RESULTS: The baseline BIS was 95±4 in this severely depressed
patient population. The pre-ECT BIS value (39±9) correlated with the
duration of both motor (r=0.34) and EEG (r=0.38) seizure activity. The
peak post-ECT value (63±15), correlated with the duration of the EEG
seizure activity (r = 0.39). A positive correlation was also found
between the EEG seizure duration and the time to eye opening (r =
0.29). However, the BIS values upon awakening from methohexital
anesthesia varied from 29 to 97, and was <60 in 75% of the cases.
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DOES CEREBRAL MONITORING FACILITATES RECOVERY significantly different from the Control group. However, the length of
AFTER GENERAL ANESTHESIA? A COMPARISON OF AEP stay in the PACU was significantly shorter in both the AEP and BIS-
AND BIS MONITORING groups.
CONCLUSIONS: Cerebral monitoring led to a reduced maintenance
AUTHORS: I. Gasanova, A. Recart, P. F. White, T. Thomas, B. anesthetic (desflurane) requirement, and a shorter length of stay in the
Oggunaike PACU after general surgery.
AFFILIATION: Department of Anesthesiology and Pain REFERENCES:
Management, University of Texas Southwestern Medical Center, 1.- Gan TJ, Glass PS, Windsor A et al: BIS monitoring allows faster
Dallas, TX. emergence and improved recovery from propofol, alfentanil, and
nitrous oxide anesthesia. Anesthesiology 1997; 87: 808-15
INTRODUCTION: The availability of cerebral monitoring has 2.- Song D, Joshi G, White PF: Titration of volatile anesthetics using
improved the ability of practitioners to titrate anesthetic drugs1,2. bispectral index facilitates recovery after ambulatory anesthesia.
However, controversy exists regarding the impact of these monitors in Anesthesiology 1997; 87:842-08
facilitating the early recovery process after surgery. This prospective
CONTROL AEP MONITORED BIS MONITORED
study was designed to evaluate the impact of intraoperative cerebral
(n= 21) (n=20) (n=20)
monitoring using either a bispectral index (BIS™) or auditory evoked
potential (AEP) monitor on the time to discharge from the recovery Age (yr) 49±14 44±14 46±17
room. Weight (kg) 93±27 91±30 90±21
METHODS: 61 inpatients undergoing general surgery procedures Fentanyl (g) 378±178 325±133 283±118
using a standardized general anesthetic technique were randomly Desflurane (ET%) 4.7±0.8 3.5±0.7* 3.7±0.4*
assigned to one of three monitoring groups: (1) Standard Practices
Surgery time (min) 112±47 105±33 107±49
(Control), (2) BIS-guided or (3)AEP-guided. Prior to induction of
general anesthesia, both the BIS and AEP monitors were connected to Eye opening(min) 9±6 7±4 6±5
each patient’s head. In the standard practices group, the Extubation (min) 13±4 9±5 8±5
anesthesiologists were not permitted to view the BIS or AAI values PACU stay (min) 113±51 56±20* 63±19*
during anesthesia. In the BIS-guided group, the volatile anesthetic was Patient satisfaction (%) 85 95 96
titrated to maintain a BIS value in the range of 45-55. In the-AEP
· * P < 0.05 vs control group
guided group, target range was 15-25. The end-tidal desflurane
concentration was recorded at 5 min intervals. Recovery times to
awakening, extubation and PACU discharge were recorded. In addition,
patient satisfaction with anesthesia (0-100) was evaluated at 24 hrs after
surgery.
RESULTS: The AEP and BIS guided groups received lower average
end-tidal concentrations of desflurane than the Standard Practice
group.However there were no significant difference between these two
monitoring groups. Although the emergence and extubation times were
consistently shorter in the AEP and BIS groups, this difference was not
2003; 96; S-1–S-293 S-131
S-130
COMPARISON BETWEEN A-LINE ARX INDEX AND surgery, incision; 7, end of propofol infusion; 8, respond to verbal
BISPECTRAL INDEX DURING PROPOFOL-FENTANYL- contact; 9, extubation. *: P < 0.05 vs. the value before LMA insertion
NITROUS OXIDE ANESTHESIA (4) or incision (6). The BIS number became > 60 in four cases but no
patients showed AAI number > 30 during anesthesia.
AUTHORS: T. Nishiyama, K. Hanaoka DISCUSSION: BIS numbers between 40 and 60 and AAI numbers <
AFFILIATION: The University of Tokyo, Tokyo, Japan. 30 are thought to be adequate during general anesthesia. Both AAI and
BIS numbers decreased during propofol-fentanyl-nitrous oxide
INTRODUCTION: Autoregressive model (ARX) with exogenous anesthesia. However, four patients showed BIS number > 60 while no
input of middle-latency auditory evoked potentials (AEP) has been patients had AAI number > 30. In addition, AAI number increased in
proposed to monitor the depth of hypnosis using an A-line response to LMA insertion and incision, but BIS number did not
autoregressive index (AAI).1 The purpose of this study was to compare respond to them. Therefore, AAI number might be more precise than
the changes of AAI and bispectral index (BIS) during propofol- BIS number in propofol-fentanyl-nitrous oxide anesthesia.
fentanyl-nitrous oxide anesthesia. REFERENCE:
METHODS: After informed consent, 40 female, aged 40 to 60, 1. Acta Anaesthesiol Scand 46,245-251,2002
without any complications scheduled for partial mastectomy were
divided into AAI and BIS groups of each 20 patients at random.
Midazolam 5 mg and atropine 0.5 mg were administered
intramuscularly 30 minutes before start of anesthesia. Anesthesia was
induced with propofol 2 mg/kg and fentanyl 3 g/kg. After loss of
consciousness, laryngeal mask (LMA) #3 was inserted. Anesthesia was
maintained with propofol 4 mg/kg/h, fentanyl 1 g/kg (total 4 g/kg), and
nitrous oxide 4 L/min in oxygen 2 L/min. Blood pressure, heart rate,
and AAI or BIS were monitored before, during and after surgery. AAI
was measured by A-line™ AEP monitor (Danmeter A/S, Odense,
Denmark) and BIS was measured by A-2000 BIS™ monitor (Aspect
Medical Systems, Newtown, USA).
RESULTS: Blood pressure and heart rate decreased significantly by
anesthesia induction and returned to the baseline at the end of surgery in
both groups without any differences between the two groups. The
numbers of AAI and BIS are shown in the table as mean values.
1 2 3 4 5 6 7 8 9
AAI 72 26 12 18* 14 19* 20 47 78
BIS 89 40 40 39 47 50 57 69 85
1, before anesthesia; 2, loss of consciousness; 3, before LMA insertion;
4, just after LMA insertion; 5, 3 minutes after LMA insertion; 6, start of
S-131
ADJUSTMENT OF ANESTHESIA DEPTH BY BISPECTRAL and 49±15 s when delivered after waiting . There was significant
INDEX ELONGATED SEIZURE DURATION IN difference in seizure duration between the two values (p<0.01).
ELECTROCONVULSIVE THERAPY DISCUSSION: Although the view that seizure duration is a primary
determinant of treatment efficacy is changing, extremely short seizure is
AUTHORS: F. Nishihara still believed to be ineffective. In conclusion, seizure duration has a
AFFILIATION: Gunma University, Maebashi, Japan. positive correlation with BIS value immediately before electrical shock.
Anesthesists can adjust anesthesia depth by BIS value to obtain a longer
INTRODUCTION: In the clinical practice of electroconvulsive seizure.
therapy (ECT), extremely short seizure and abortive one are considered REFERENCES:
to be ineffective (1). Since significant correlation between seizure 1) Anesth Analg 91: 1531-6, 2000
duration and bispectral index (BIS) value immediately before electrical 2) Anesth Analg 93: 1249-52, 2002
stimulus has been reported (2), adjustment of anesthesia depth by BIS
may be effective to obtain a desired seizure length. In the present study,
we examined the hypothesis in the subjects who had short seizure
length in an ECT trial.
METHODS: ECT was prescribed to 15 patients suffering from
endogenous depression. Atropine (0.01 mg/kg) im was given as
premedication. The BIS electrode was attached to forehead of the
patients as instructed by the manufacturer. Single lead
electroencephalography (EEG) was recorded on the same monitor.
General anesthesia was induced with propofol (1-2 mg/kg). After loss
of consciousness, succinylcholine chloride (1 mg/kg) was administered
and ventilation was assisted using a face mask and 100% oxygen. The
electroshock stimulus was delivered by a trained psychologist using
ECT-stimulator. The efficacy of electrical stimulation was determined
by tourniquet technique, electromyogram and electroencephalography.
Consciousness was assessed by calling patient's name every 30 seconds
after the start of spontaneous respiration. When a patient had a short
seizure, in the next ECT trial, the patient received electrical stimulus
after waiting an elevation in BIS value (+10-20). Intensity of electrical
stimulus and anesthesia condition were identical in the two trials.
RESULTS: The patients ranged from 22 to 80 years of age. Intensity of
stimulus was 36±15%. No patient could recall ECT procedures, and no
complaint was reported after ECT regardless the BIS score prior to
electrical shock. All patients had longer seizures when stimulus was
delivered after BIS elevation. Seizure duration measured by muscle
movement was 36±10 s when stimulus was delivered without waiting
S-133 2003; 96; S-1–S-293
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THE AUDITORY EVOKED POTENTIAL AND THE
BISPECTRAL INDEX: A COMPARISON STUDY EXAMINING
SIGNAL RESPONSES TO INADEQUATE ANESTHESIA
AUTHORS: S. C. Manyam, D. M. Chatwin, J. A. Decou, K. B.
Johnson, J. L. White, T. D. Egan
AFFILIATION: University of Utah, Salt Lake City, UT.
INTRODUCTION: The processed auditory evoked potential (AEP)
and the bispectral index scale (BIS) of the electroencephalogram are
two mechanistically different technologies used to assess the effect of
anesthetics on the central nervous system. The aim of this study was to
examine how the AEP and BIS change in response to noxious
stimulation when anesthesia is inadequate.
METHODS: After obtaining institutional approval and informed
consent, 8 healthy adult male and female volunteers were enrolled.
Volunteers received remifentanil (REMI) and sevoflurane (SEVO) at
various target concentration pairs (TCPs) spanning the entire clinical
spectrum (i.e., REMI from 0-80 ng/ml by computer controlled infusion
and SEVO from 0-7%). AEP, BIS and heart rate (HR) were digitally
acquired for later analysis. Baseline AEP and BIS values were recorded * The study was supported in Part by Alaris medical systems
at each steady state TCP after which a series of experimental pain * Dr. Talmage Egan is a consultant to Alaris medical Systems
measures were randomly applied (pressure algometry on the leg to 50
psi, electrical tetany on the leg to 50 milliamps and thermal stimuli to
the forearm to 50 C). Inadequate anesthesia was defined as subject
movement or a HR increase of 20%. The magnitude of AEP or BIS
change in the first minute after inadequate anesthesia was observed was
considered the outcome of interest; these maximal AEP and BIS values
were extracted from 10 second time averaged AEP and BIS signal from
the digital data files. AEP or BIS signal with artifactual corruption (e.g.,
movement, etc.) was not analyzed. The magnitude of the changes
normalized to the maximal AEP and BIS values (in the first minute after
stimulation) were plotted for each painful stimulus at all TCPs.
RESULTS: All 8 subjects completed the experiment. Percentage
increase in AEP and BIS for each painful stimulus type are shown in the
figure for all TCPs. A greater percentage increase in AEP than BIS is
seen in most observations.
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INCIDENCE OF AWARENESS USING BIS-MONITORING
AUTHORS: C. Lennmarken1, A. Ekman2, R. Sandin3
AFFILIATION: 1Department of Anaesthesia and Intensive Care,
Linköping, Sweden, 2Department of Anaesthesia and Intensive Care,
Kallmar, Sweden, 3Department of Anaesthesia and Intensive Care,
Kalmar, Sweden.
INTRODUCTION: Explict recall (ER) of events during relaxant
anesthesia is evident in approximately 0.2% of cases when no
neurophysiological monitoring is used to guide the conduction of
anesthesia (1). The likelihood of severe neurotic sequelae among
patients experiencing intraoperative wakefulness with ER is substantial
(2). No previous study has assessed if incidence of ER can be reduced
by neurophysiological methods. We assessed the incidence of ER when
BIS monitoring was used.
METHODS: BIS monitoring was used in 5057 consecutive patients
older than 16 years undergoing relaxant anesthesia. The patients were
interviewed for ER on three occasions within the first 14 days after
anesthesia. The result was compared with historical data on the
incidence of ER when no neurophysilological monitoring was used
from the same two institutions (1).
RESULTS: 2 cases with ER were identified among 5057patients
(0.04%); p<0.039 as compared with our historical material. Both
identified cases were aware during intubation and were associated with
significantly higher BIS values than the patients with no ER. The BIS
values in these 2 patients were also higher than the highest value
recommended by the manufacturer.
DISCUSSION: The use of BIS in relaxant anesthesia was associated
with a significantly reduced incidence of ER as compared with a
historical material from the same 2 hospitals. The incidence found is the
lowest ever reported in a reasonably large study. The interpretation of
this should take the Hawthorne effect and other possible factors due to
the non-randomized design into consideration.
REFERENCES:
1. Lancet 2000:355:707-711.
2. Acta Anaesthesiol Scand 2002;46:229-231.
2003; 96; S-1–S-293 S-135
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EVALUATION OF BISPECTRAL INDEX (BIS) IN be taken to assure an adequate anesthetic depth prior to a surgical
TRAUMATIZED PATIENTS PRESENTING ACUTELY TO THE stimulus or be aware of the fact that the patient may have awareness of
OPERATING ROOM ongoing events.
We must attempt to identify those subclasses of patients who are at risk
AUTHORS: E. R. Deal, I. Gratz, M. E. Goldberg of recall of surgical stimulus and treat appropriately. Further
AFFILIATION: The Cooper Health System, Camden, NJ. investigations are needed to determine if in these particular patient
populations higher BIS readings lead to an increase in postoperative
INTRODUCTION: Trauma is one of the leading causes of morbidity recall of preoperative events. The use of suitable protocols for the
and mortality in young and middle age Americans. Many present to proper titration of sedation of mechanically ventilated patients and the
Trauma Centers in need of emergent or urgent surgical intervention. monitoring of the level of sedation appears indicated. None of the
Frequently these patients are told they are going to be “put to sleep” to patients in this small study reported recall of preoperative events.
help control their pain and anxiety. The Bispectral Index is frequently
used as an adjunct in the monitoring of patients receiving anesthetic
care. The BIS is a dimensionless scale based on EEG, Beta activity and
burst suppression. The purpose of this investigation was to evaluate the
level of sedation by utilizing the BIS monitor in traumatized patients
who presented to the operating room after being anesthetized and
intubated in the trauma area.
METHODS: Thirty-two trauma patients who presented to the OR in
this IRB exempt study for orthopedic, intra-abdominal, intra-thoracic or
vascular procedures, were evaluated using a (BIS) monitor prior to
receiving anesthetic agents in the operative suite. Patients who had
known neurologic injuries were excluded from the investigation.
RESULTS: The range of the collected data was 51-94. The mean was
74.1 and the median was 76.5. There were 11/32 - 34.4% patients with
BIS readings greater than 80. 16/32 - 50% had a reading between 60
and 80 and 5/32 had a reading less than 60.
DISCUSSION: Trauma continues to play a pivotal role in healthcare
today. Many are faced with the challenges of adequately managing a
patient who has recently been involved in a major trauma. Frequently
these traumatized patients are brought to the operating room for
emergency operative procedures. These may be orthopedic, vascular or
exploratory in nature. Many of these patients are anesthetized in the
trauma area for pain management and anxiolysis. In our investigation
11/32 or 34.4% of the patients had a BIS reading greater than 80,
indicating that perhaps up to the 1/3 of the patients may not be
adequately sedated, and be cognizant of their surroundings. Care must
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MONITORING ENTROPY OF THE COMPOSITE EEG AND induction. The probability curves were calculated using logistic regression
FEMG SIGNAL DURING GENERAL ANESTHESIA analysis. On average, these patients lost consciousness at SE/RE values of
81/86. For the other drug combinations, the corresponding values were 76/
AUTHORS: H. Viertiö-Oja1, V. Maja1, P. Talja1, N. Tenkanen1, H. 81 (propofol), 82/87 (thiopental) and 78/81 (alfentanil + midazolam).
Tolvanen-Laakso1, A. Yli-Hankala2 DISCUSSION: The steep probability curve for State Entropy in Fig. 1
AFFILIATION: 1Datex-Ohmeda, Helsinki, Finland, 2Tampere indicates that all the patients induced with sevoflurane in this study lost
University Hospital, Tampere, Finland. consciousness at approximately the same State Entropy value. This
suggests that this parameter well accommodates to interindividual
INTRODUCTION: In information theory and signal analysis, entropy variations. Response Entropy was found informative in providing rapid
addresses the irregularity, complexity, or unpredictability characteristics of indication of FEMG reaction to nociceptive stimulation and during
a signal [1]. With respect to anesthesia, there is ample evidence that emergence from anesthesia.
electroencephalographic (EEG) signal data contains more "order", i.e. less REFERENCES:
"irregularity", and lower entropy at higher concentrations of an anesthetic [1] Stochastic complexity measures for physiological signal analysis, IEEE
agent, than at lower concentrations [1-3]. Entropy is a scale-invariant Transactions on Biomedical Engineering, Vol. 4, No. 9, September 1998,
measure that is independent of the frequency and amplitude scales of the pgs. 1186-1191,
signal. This suggests that it may better accomodate to the interindividual [2] Approximate Entropy as an Electroencephalographic Measure of
variability of the EEG rhythms than the conventional techniques. Anesthetic Drug Effect during Desflurane Anesthesia, Anesthesiology, 92
METHODS: Clinical application of the concept of spectral entropy, to (2000), pgs. 715-726
quantify the irregularity of a biopotential signal including EEG and facial [3] Entropy of EEG signal is a robust index for depth of hypnosis,
electromyographic (FEMG) signals, is investigated. The contribution to Anesthesiology 93 (2000) A, pg. 1369
spectral entropy from any particular frequency range can be explicitely
separated. It is informative to define two entropy indicators: 1) State
Entropy is computed over the EEG dominant frequency range alone
whereas 2) Response Entropy includes both EEG and FEMG components.
Sudden appearance of FEMG activity often indicates that the patient is
responding to an external stimulus, such as a intubation. Such a response
may result if the level of analgesia is insufficient. FEMG can also provide a
rapid indication of impending arousal. As the FEMG signal consists of
higher frequencies than the EEG signal, the response time of Response
Entropy may be significantly faster (2 s) than the response time of State
Entropy (15 s). These entropy parameters were measured for 69 patients
undergoing general anesthesia. Anesthetics included propofol, thiopental,
sevoflurane, and a combination of midazolam and alfentanil. Patients were
considered unconscious when they no longer responded to verbal
commands.
RESULTS: Figure 1 shows the probability of consciousness as a function
of Response/State Entropy values for 18 patients with sevoflurane
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A PROTOTYPE NEUROMUSCULAR MONITOR USING signal height during surgery, signals measured, recorded and displayed
PHONOMYOGRAPHY according to the stimulation frequency (here every 12 s). The lower
graphic shows the typical early onset and recovery of the corrugator
AUTHORS: T. M. Hemmerling, G. Trager, D. Babin, F. Donati, P. supercilii muscle. This two graphical displays of neuromuscular
Mathieu blockade of the two muscles during surgery can be separately printed
AFFILIATION: University of Montreal, Montreal, PQ, Canada. either for research purposes or clinical documentation. The program is
designed in such a way that any signal with an amplitude greater than
INTRODUCTION: Recently, phonomyography using small condenser 150 % of the reference amplitude is automatically erased. Using this
microphones has proven to be a reliable monitor of neuromuscular design, we could erase electrocautery artefacts in the trend graphics.
blockade, applicable at different muscles, such as the larynx (1), CONCLUSION: This prototype allows the simultaneous measurement,
corrugator supercilii muscle (2) or adductor pollicis muscle (3). This recording and display of two phonomyographic signals. It is a first step
project was aimed to develop a prototype neuromuscular monitor using towards a more detailed and sophisticated neuromuscular monitor for
phonomyography to simultaneously monitor the evoked response of the daily practice using phonomyography
corrugator supercilii muscle and the adductor pollicis muscle. REFERENCES
METHODS: The prototype neuromuscular monitor consists of a 1 CAS 2002, abstract presented at the CAS meeting june 2002, Victoria
portable, equipped with a Labview software and data acquisition card. 2 Br J Anaesth 2002 ; 88 : 389-93
The data acquisition card receives signals from two amplifiers, 3 ASA 2002, abstract.A-987
amplifying the phonomyographic signals of two small condenser
microphones placed over the corrugator supercilii muscle and adductor
pollicis muscle as described before (2,3). Stimulation of the ulnar and
facial nerve is performed using routine nerve stimulators. The project
consisted of using Labview software to design a neuromuscular monitor
surface displaying evoked signals from the two muscles in real time
(after either single-twitch or train-of-four stimulation), digitising the
evoked signals in reference to control amplitude defined with
supramaximal stimulation for both muscles during induction period
before applying the muscle relaxant. Thus a graphical trend of the
neuromuscular blockade during surgery should be displayed in
percentage of the control signal. A significant part of the project
consisted of analysing and diminishing artifact influences due to
electric appliances in the OR.
RESULTS: Figure 1 shows the display screen of the prototype. It
shows the signals of the two muscles in real time (here TOF stimulation,
corrugator supercilii muscle left) and allows the objective determination
of signal shape, possible artefacts, signal quality and fade. Train-of-four
ratio is automatically detected and digitally displayed. The wide, two
bottom screens show T1 signal height in percentage of the control
S-137
CORRELATION BETWEEN STROKE VOLUME AND LEFT coefficients between SV and LVETi for all seven patients was s=0.71
VENTRICULAR EJECTION TIME IN THE PRONE POSITION (p=0.07). Individual patients showed a strong clinical correlation
USING TRANSESOPHAGEAL ECHO-DOPPLER between SV and LVETi for multiple time points throughout the study (s
MONITORING. > 0.5).
DISCUSSION: There was a strong positive clinically significant
AUTHORS: G. Martin1, D. S. Breslin1, F. D'Ercole1, S. A. Grant1, D. correlation between SV and LVETi in the prone position for all seven
B. MacLeod1, D. H. Gleason2 patients. Approximately 50% of change in SV variance was explainable
AFFILIATION: 1Duke University Health System, Durham, NC, 2Duke by changes in LVETi. LVETi, an indicator of preload may be a useful
parameter in maximizing SV of patients undergoing surgery in the
University Health System, Durham, ND. prone position. It is likely that the inability to obtain the conventional
INTRODUCTION: The relationship between stroke volume (SV) and threshold of statistical significance even though the magnitude of the
left ventricular ejection time (LVETi) in the prone position has not been correlation was clinically significant is related to the small sample size.
examined. In the supine position there appears to be a strong positive REFERENCES:
clinical correlation between LVETi and SV. 1 LVETi is the time from 1. Anesthesiology 2001; 95: A542.2. J Clin Monit 2000; 16: 127-40.
opening to closure of the aortic valve indexed to the heart rate, and is an
indicator of preload. We examined the relationship between SV and
LVETi in the prone position after rapid colloid administration using a
Transesophageal echo-doppler monitoring device (Hemosonic ®, Arrow
International, Reading, PA). 2 This is a non-invasive, real-time monitor
of cardiac function allowing the measurement of aortic blood flow,
cardiac output, SV, total systemic vascular resistance, and LVETi.
METHOD: Institutional review board approval for this study was
obtained. Seven patients undergoing lumbar spinal instrumentation in
the prone position were included in this study. Anesthetic management
was standardized for all patients. An esophageal echo-doppler was
placed in all patients after induction of anesthesia and baseline
hemodynamic variables were monitored once the patient was in the
prone position. Patients were challenged with repeated 250 ml boluses
of colloid over 2.5 min in an effort to increase their SV by 5 - 10% from
baseline. Data was recorded from the transesophageal echo-doppler
monitor at baseline, prior to each fluid bolus, and at the end of each
fluid bolus. Spearman rank correlation coefficients were used to assess
the association between SV and LVETi. A p < 0.05 was considered
significant.
RESULTS: The mean (SD) SV change from before to after the third
fluid bolus was -9.5 mL (16.4) with p=0.2. The corresponding mean
(SD) LVETi change was -24.7 ms (31.5) with p=0.08. The correlation
2003; 96; S-1–S-293 S-139
S-138
EVALUATION OF A CARDIAC OUTPUT MONITOR (NICO) measure CO. There are problems in measuring differential CO2
DURING AORTIC ANEURYSM REPAIR production, as well as problems in using differential end tidal CO2 as a
measure of differential arterial CO2. The cases examined show a
AUTHORS: R. J. Roy remarkable disparity in results. Over half the results were not
AFFILIATION: Albany Medical Center, Albany, NY. acceptable for clinical use, while almost half were considered to be
good to excellent. The reasons for this disparity are not clear, but it
INTRODUCTION: Following introduction1 of a CO2 based appears that patient habitus and position may cause ventilation-
differential Fick method to measure cardiac output, the non invasive perfusion ratios that are difficult to handle with the present software.
cardiac output (NICO)2 device (Novametrix Corp.) was introduced and REFERENCES:
has received clinical acceptance3 in a range of situations.This study 1. IEEE Trans.BME Vol.35 p.653, 1988
looked at patients undergoing aortic aneurysm repair using the 2. J.Clin.Mon. Vol.16 p361, 2000
retroperitoneal approach, requiring positioning in the right lateral 3. Acta Anesth.Scand. Vol. 46 p152, 2002
position. This combination often has significant fluid shifts combined
with ventilation-perfusion abnormalities which may present a difficult
challenge for this technique.
METHODS: Following induction, an A-line and a S-G catheter were
placed. Arterial blood gas values initialized the NICO and updated the
NICO every hour. Every 15 min. a thermodilution (TD) cardiac output
(CO) was obtained and recorded along with the CO reading of the
NICO. For each of the 25 patients a plot of the simultaneous values of
the TD and NICO was made. The statistical studies made on this data
were correlation, Bland Altman, percentile closeness of fit, and a
judgment made for each patient by a group of anesthesiologists as to
whether the fit by the NICO compared to the TD was either Excellent,
Good, Fair, or Poor.
RESULTS: A total of 323 paired values were obtained. The correlation
coefficient between these paired values was 0.61. The Bland -Altman
study shows a bias of -0.70 with 95% limits of agreement (-3.1,1.7).
The S.D. of the difference was 1.21. The percentage of NICO points
lying within 10% of the TD values was 33.7%, and within 20% was
54%. The consensus opinion of the anesthesiologists as to the fit of the
NICO compared to the TD on each of the 25 patients was E: 4, G: 7, F:
5, P: 9. Thus, in only 11 of the 25 cases was the NICO considered to be
a good to excellent substitute for the TD, and in 14 of 25 cases it was
considered to be a poor to fair substitute.
CONCLUSIONS:. The NICO device employs a differential form of
the Fick equation, thus making it unique among the methods used to
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NONINVASIVE CARDIAC OUTPUT MONITORING ascites, abdominal distention or diarrhea were not significantly different
FACILITATES INTRAOPERATIVE FLUID MANAGEMENT between groups. Urine output was significantly greater in Group A:
FOR MAJOR GYNECOLOGIC ONCOLOGY PROCEDURES 80cc/hr surgery ( 24-138)(median, range) vs. Group B: 37 (27-60) cc/hr
surgery (P=0.05). Group A: 126 min LVETc> 350ms (78-268) (median,
AUTHORS: R. L. Marcus, S. Ahmad, N. Crnkovich, S. Glisson, T. range). Group B: 53 min LVETc > 350 ms (13-195) (P<0.05)
Gregory Patients postoperative length of stay for Group A: 2.91 (1.25-7.06) days
AFFILIATION: Northwestern University Feinberg School of (median, range)vs. Group B: 3.98 (2.29-8.98) days (P=0.21).
Medicine, Chicago, IL. DISCUSSION: This study has demonstrated that intraoperative fluid
management and optimization of left ventricular performance in major
INTRODUCTION: Perioperative hemodynamic monitoring and fluid gynecologic oncology surgery is facilitated by use of the HemoSonic™.
management is often challenging in the ovarian cancer patient LVETc, a quantitative assessment of left ventricular performance, was
undergoing hysterectomy and staging laparotomy. The noninvasive above 350ms (reference range: 330-360ms)1 more often in Group A.
transesophageal echo-Doppler device (HemoSonic™ 100 Arrow This may explain the greater intraoperative urine output in Group A
International, Reading, PA) allows for easy, real time assessment of despite having similar fluid intake and blood loss as in Group B. After
cardiac output, stroke volume, left ventricular ejection timecorrected accounting for initiation of chemotherapy, Group A's duration
(LVETc,) and calculated total systemic vascular resistance. This study postoperative stay was one day shorter than Group B. This is clinically
evaluated the effectiveness of the HemoSonic™ as an aid to significant and may impact on cost of care. Another study involving
intraoperative fluid management in this patient population. intraoperative fluid expansion guided by esophageal Doppler reported a
METHODS: Following IRB approval 22 patients diagnosed with mean reduction in hospital stay by 2 days.2
ovarian cancer and scheduled for hysterectomy and staging laparotomy REFERENCES:
were randomized to two groups: Group A: (protocol) subjects received 1. Weissler AM, et al (Circulation 1968;37:149-159)
100 cc boluses of hetastarch (Hextend™Abbott Laboratories, North 2. Gan TJ, et al (Anesthesiology 1999;91: A537)
Chicago, IL) to maintain stroke volume 10-15% above the baseline
obtained 15 minutes after induction of anesthesia. If stroke volume was
within normal range but the patient's MAP was below 30% of baseline,
obtained in our preoperative clinic, fluid therapy was instituted as in the
control group.
Group B: (control) subjects received 100cc boluses of hetastarch when
MAP decreased below 30% . Each group received 100 cc boluses of
hetastarch for urine output <0.5ml/kg/hr. Blood loss was replaced 1:1
with hetastarch. For Hgb< 7.0 g/dl or < 8.0 g/dl in patients with
significant cardiac disease, PRBCs were transfused. Preoperative fluid
management, anesthetic technique and postoperative epidural analgesia
were standardized in both groups.
RESULTS: Seventeen patients completed the study. Patient
demographics, surgical time, fluid intake (crystalloid + colloid), blood
loss, episodes of nausea, vomiting, ascites, gas pain, reaccumulation of
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TRUCCOMS--AN ACCURATE SYSTEM FOR CARDIAC CONCLUSION: In the clinical situation there will be wide variation in
OUTPUT MEASUREMENT? the conditions encountered by the heat transfer device (heated coil) in
the pulmonary artery. The change in the artificial heart stroke volume,
AUTHORS: P. R. Lichtenthal1, U. R. Borg2 especially at low stroke volumes with short systolic time, models well
AFFILIATION: 1University of Arizona, Tucson, AZ, 2Technical the clinical response to hypovolemia. The resultant turbulent conditions
College of Orebro, Orebro, Sweden. may lead to overestimation of flow by the heat transfer technology.
Hence, clinically unacceptable values may result in patients with
A new method for continuous cardiac output (CCO) determination hypovolemia and tachycardia. Further refinements of this technology is
based upon heat transfer technology was recently introduced needed prior to its use in clinical care.
(truCCOMS, AorTech International, Plc, Scotland). The method utilizes
a heated coil placed on a pulmonary artery catheter. The heat transfer
method relies on maintaining a constant temperature difference between
the heated coil and the blood. The power necessary to maintain this
temperature difference is proportional to the blood flow.
METHODS: We investigated the accuracy of the truCCOMS using a
Donovan Mock Circulation Tank with a CardioWest Artificial Heart
providing pulsatile flow. A glycerol solution at 37 C with heat capacity
and viscosity similar to blood was used in the tank. The flow in the
pulmonary artery of the mock circulation was measured with a transit
time ultrasonic flow probe (TTF) (Transonic) and compared to flow
measurements obtained by truCCOMS. Fluid flows from 1 - 8 L/min
were utilized to test 10 heat transfer pulmonary artery catheters.
RESULTS: Thr relationship between CCO and TTF was examined
using bias and precision, linear regression and Pearson correlation
coefficient. The correlation was r2= .803 (Fig 1 top) and bias = 0.53 L/
min with a precision of +- 1.33 L/min (Fig 1 bottom).
DISCUSSION: The lack of precision or high degree of scatter in
Figure 1 can be explained by the dependence of heat transfer
technology on predictable turbulent flow for accuarate measurement.
Furthermore, heat transfer technology is in general best applied to
constant flow. The flow pattern of the pulsatile flow in the pulmonary
artery is dependent on geometry of the vessel as well as speed of
contraction and geometry of the pulmonic valve. Despite the constant
geometry and diameter of the pulmonary artery and pulmonic valve in
the model, large variations were found in the truCCOMS CCO
determinations.
S-141
SOURCES OF ERROR IN NON-INVASIVE PULMONARY delay and mixing caused by the gas movement in the airways during tidal
BLOOD FLOW MEASUREMENTS BY PARTIAL RE- expiration. The alveolar-capillary PCO2 gradient increases with cardiac
BREATHING: A COMPUTER MODEL STUDY output due to decreased capillary residence times, hence creating a
systematic error in PBF that increases with PBF. Re-breathing times that at
AUTHORS: J. S. Yem, Y. Tang, M. J. Turner, B. A. Baker low PBF's are inadequate to achieve quasi-equilibrium in the alveolar
AFFILIATION: Department of Anaesthetics, University of Sydney, compartment, are too long at high PBF's causing errors due to re-
Royal Prince Alfred Hospital, Sydney, Australia. circulation. Our simulations suggest that errors can be reduced by using a
variable re-breathing time, which should be increased at low PBF so that
INTRODUCTION: Partial re-breathing is a non-invasive method for quasi-equilibrium in the alveoli can be achieved, and decreased at high PBF
measuring pulmonary blood flow (PBF). The technique requires the subject to reduce the effects of re-circulation.
to breathe through an altered dead-space and uses a differential form of the REFERENCES:
Fick mass balance equation to calculate PBF from end-tidal airway CO2 1. MED BIOL ENG COMPUT;18:411-418;1980
partial pressures (PetCO2) and airway CO2 flux. 1 This study examines the 2. Morphometry of the Human Lung; Chap 10&11:110-143;1963
systematic errors produced by the partial re-breathing technique utilising a 3. RESPIR PHYSIOL;54:381-396;1983
comprehensive mathematical model of the cardio-respiratory system of a 4. Report of the Task Group on Reference Man; 280-285;1975
healthy 70 kg adult male. 5. J APPL PHYSIOL;22:260-276;1967
METHODS: The model simulates tidal breathing through a branched 6. RESPIR PHYSIOL;4:270-280;1968
respiratory tree 2 and incorporates the effects on CO2 dynamics of lung
tissue mass 3, vascular transport delays 4, multiple body compartments 5 and
realistic blood-gas dissociation curves 6. The model includes an additional
variable dead-space, that can be switched in and out to simulate the re-
breathing process. Four studies were performed to study: 1) errors produced
under standard conditions, 2) effects of re-circulation, 3) effects of
alveolar–proximal airway differences and 4) effects of rebreathing time.
RESULTS: Systematic errors are < 10% when the simulated PBF is
between 3 and 6 l/min. (Fig 1) At 2 l/min PBF is overestimated by 35%. At
14 l/min PBF is underestimated by 40%. At PBF > 6 l/min re-circulation
causes 60% of the systematic error, alveolar – proximal airway differences
20% and alveolar – arterial differences 20%. The standard re-breathing time
of 50 s is shown to be excessive for PBF > 6 l/min. At PBF <3/min errors
are caused by inadequate re-breathing time and alveolar-arterial gradients.
DISCUSSION: Simulated measurements in which we used constant
mixed venous PCO2 and PO2 suggest that increases in mixed venous PCO2
during re-breathing cause approximately 60% of the total systematic error
in measured PBF at high cardiac outputs. PetCO2 differs from mean PACO2,
even in an ideal, single compartment homogenous lung, due to the time
2003; 96; S-1–S-293 S-143
S-142
GAS COMPOSITION OF PNEUMOPERITONEUM DURING highest FPNOP N2O (%) highest FPNOP air (%)
LAPAROSCOPIC GYNECOLOGIC PROCEDURES PNOP
median (min - max) median (min - max)
AUTHORS: A. Meyer1, C. Schaeffer2, J. Raiga1, R. Schaeffer1, M. Insufflated n = 39 1.7 (0.4 – 4.8) Traces only
Henri1, P. Diemunsch1 Exsufflated n = 11 5.6 (0.7 – 14.8) * 78.2 (18.4 – 95.2)
AFFILIATION: 1CHU, Strasbourg, France, 2LSMBO, Strasbourg,
France. Table 1 p<0,01, I vs E; Wilcoxon
INTRODUCTION: During laparoscopic surgery, the carbon dioxide DISCUSSION: The results show a significant difference in FPNOPN2O
(CO2) insufflated into the peritoneal cavity constitutes a diffusion space during insufflation and after exsufflation (when the laparoscopic
for the nitrous oxide (N2O) used for anesthetic maintenance. This study procedure included a period of exsufflation). During insufflation,
FPNOPN2O remains low, because of the PNOP renewal induced by the
was designed to confirm and to quantify, in a clinical setting, this
phenomenon previously reported in an experimental environment [1]. surgical leaks. Conversely, after exsufflation the residual PNOP is no
METHODS: With IRB approval and informed consent, ASA I/II adults longer renewed. This allows for N2O to accumulate into this residual
scheduled for laparoscopic gynecologic procedures under general PNOP (maximum observed FPNOPN2O: 14.8%), and for air to enter
anesthesia (propofol TCI, sufentanil, rocuronium, 66% N2O in O2) were through the perivaginal peritoneal incision (maximum FPNOP air: 95.2%).
enrolled. Minute ventilation was adjusted to keep PETCO2 between 34 Despite usual low N2O and air levels in the PNOP, higher values can be
and 36 mmHg. The abdominal cavity was insufflated to 14 mmHg, and observed at times during surgery in humans. Clinical implications
leaks were compensated for, by CO2 from the insufflator. Some of the related to these findings must be further investigated, with a special
procedures included a transvaginal operative approach, with exsufflated focus on the potential risk associated with gas embolism.
pneumoperitoneum (PNOP). Peritoneal gas samples (10 mL) were REFERENCES:
drawn every 2 min, starting 5 minutes after PNOP insufflation, until the 1.Anesth Analg. 2000; 90:951-3
end of the procedure, and analyzed for air, CO2, and N2O fractions
(FPNOP) (gas chromatograph P200; MTI Analytical Instrument, CA,
USA).
RESULTS: Forty patients were included and one excluded for
incomplete data. Eleven procedures involved a transvaginal step. The
volume of CO2 needed to establish the PNOP was 4.4 ± 2.1 L and the
CO2 flow necessary to maintain the PNOP pressure was 2.0 ± 1.5 L/
min. The duration of the insufflation (I) and exsufflation (E) / was 56.3
± 21.2 and 32.9 ± 13.6 min. respectively. The highest peritoneal N2O
and air fractions recorded during the I and E periods are presented in
table 1. No correlation was found between the leak flow, the I and E
times and the highest observed values for N2O fraction.
S-143
THE EFFECTS OF PATIENT POSITIONING ON inspiratory pressure increased (table 1). During the fowler position the
RESPIRATORY MECHANICS ON SEVERE COPD PATIENTS respiratory compliance increased significantly again although it
DURING PNEUMOPERITONEUM remained well below the post induction value. At the same time peak
inspiratory pressure and respiratory resistance decreased.
AUTHORS: Z. Salihoglu, S. Demiroluk, O. Demirkiran, S. DISCUSSION: It is suggested that fowler position has no significant
Cakmakkaya, Y. Kose advantages patients with COPD during pneumoperitoneum.
AFFILIATION: Istanbul University, Cerrahpasa Tip Fakultesi, REFERENCES:
Istanbul, Turkey. 1)The Merck Manual, Berkow R (ed) Merck co. inc Rahway,
NJ1987:636.
INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is 2) Global Initiative for Chronic Obstructive Lung Disease (GOLD)
generalised airways obstruction, particularly of small airways, guidelines for chronic obstructive pulmonary disease. Curr Opin Pulm
associated with varying combination of chronic bronchitis, asthma and Med. 2002; 8: 81-86.
emphysema (1). In this study, the effects of patient positioning on
respiratory mechanics are compared on COPD patients during Table I: Respiratory mechanic values (mean±standard deviation)
pneumoperitoneum. Periods Induction Pneumoperitoneu Fowler Desufflation
METHODS: After ethics committee approval and written informed
consent from patients, 20 ASA III patients included in this study. All Cdyn (mL cm H2O-1) 41±6 27±4 28±4 37±7
patients were diagnosed as having severe COPD according to the Raw (cm H2O L-1 sn-1) 17±4 22±4 21±4 19±3
GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria
(2). The standard anesthesia and monitorization has been used. During PIP (mmHg) 21±5 25±4 24±4 21±4
the operation, ventilation was controlled artificially. Tidal volume and
ventilator frequency were kept constant throughout the operation. Gas
insufflation was performed 2 L min-1 and the intraabdominal pressure
was kept constant at 12 mmHg. VenTrak (novometrix,USA) respiratory
mechanic device was used for measuring respiratory mechanics. The
resistance of airway (Raw), the dynamic compliance (Cdyn), and the
peak inspiratory pressure (PIP) were measured. Measurement was
performed in four periods: after anaesthesia induction (induction), 5
minutes after insufflation of the peritoneum (pneuomoperitoneum), at
25° Fowler position (fowler),and 5 minutes after desufflation of the
peritoneum ( desufflation). Statistical analysis; Values are expressed as
mean ± standard deviation. Statistical analysis was carried out using
repeated measures ANOVA with Tukey Kramer post test to evaluate the
differences between the established study points. A p value <0.05 was
RESULTS: During pneumoperitoneum and fowler position,
respiratory compliance decreased, while respiratory resistance and peak
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VAGAL NERVE BLOCKADE INCREASES DEAD SPACE the matching of pulmonary blood flow to lung volume during each
VENTILATION IN HUMAN respiratory cycle.
CONCLUSION: Blocking vagal nerve activity with atropine in human
AUTHORS: S. Ito1, H. Sasano1, N. Sasano1, Y. Tomita1, H. Katsuya1, J. increased anatomical dead space. Vagal nerve activity may improve the
A. Fisher2 efficiency of ventilation at rest in human, decreasing physiological dead
AFFILIATION: 1Department of Anesthesiology and Medical Crisis space, at least anatomical dead space.
Management Nagoya City University Graduate School of Medical
Sciences, Nagoya, Japan, 2Department of Anesthesia, University Health
Network, University of Toronto, Toronto, Canada, Toronto, ON,
Canada.
INTRODUCTION: Vagal nerve outflow is linked to respiration.
Increased vagal outflow may result in tracheal and bronchial
constriction and reduce anatomical dead space. The increase in vagal
outflow in synchrony with expiration accentuates sinus arrhythmia
which may improve the matching of pulmonary blood flow to lung
volume during each respiratory cycle. We made an assumption that
blocking vagal nerve activity with atropine in human would increase
both anatomical dead space and alveolar dead space.
METHODS: 5 volunteers breathed at a given tidal volume and
respiratory frequency (15/min) in synchrony with a metronome signal.
The mean amplitude of the high-frequency component of R-R interval
variation (RRIHF) from ECG signal was used as an index of cardiac
vagal tone. Anatomical dead space (VDaw) , alveolar dead space
(VDalv), physiological dead space ventilation/tidal volume (VD/VT)
and pulmonary capillary blood flow (PCBF) were measured by
NICOTM (Novametrix Inc.) before and after atropine administration
(0.02 mg/kg).
RESULTS: Atropine increased heart rate and decreased the RRIHF.
Atropin increased VDaw and VD/VT significantly (p<0.05) (Figure),
but VDalv did not change significantly. PCBF decreased (~15%) after
atropine administration, but the change did not reach statistical
significance.
DISCUSSION: Vagal nerve blockade increased VDaw and VD/VT.
The decrease in PCBF suggests that pulmonary blood flow contributing
to CO2 excretion decreased as a result of the abolition of the vagally-
mediated respiratory modulations in pulmonary blood flow, weakening
S-145
FLOW RESISTANCE OF THE BICORE VARFLEX FLOW Table of results (see text)
TRANSDUCER IFA IFM IPP IR EFA EFM EPP ER
AUTHORS: G. Aguilar, R. Ferrandis, F. Belda, M. Soro, M. L. Garcia- 0.25 0.3 + 5E-3 0.7 + 0.02 2.3 + 0.07 0.25 0.24 + 4E-3 0.7 + 0.03 2.8 + 0.16
Perez, M. Garcia-Raimundo 0.50 0.6 + 9E-3 1.3 + 0.04 2.3 + 0.09 0.50 0.3 + 0.01 1.2 + 0.05 2.4 + 0.11
AFFILIATION: Hospital Clinico Universitario, Valencia, Spain. 1.00 1.1 + 5E-3 4.2 + 0.04 3.9 + 0.05 1.00 1.00 + 5E-3 4.6 + 0.04 4.6 + 0.06
INTRODUCTION: Bicore CP-100 monitor is using in many clinical

studies of mechanical ventilation. VarFlex Bicore flow transducer
accuracy has been already demonstrated. However there are not
published data on transducer flow resistance. We measured inspiratory
and expiratory resistance of this transducer at different levels of gas
flow (GF).
METHODS: A constant GF delivered from a constant flow generator
(precalibrated against a bell spirometer) was adjusted to 0.25, 0.5 and
1.0 L/sec. GF passed through a VarFlex flowmeter and proximal
pressure was measured at each GF rate using a precalibrated Copal P-
3000 (Japan) pressure transducer. Pressure drop was measured in both
inspiratory and expiratory senses. GF rate delivered and proximal
pressure were measured in quintuplicate. Resistance was derived from
P/V× ratio.
RESULTS: Mean ± SD values obtained are shown in the table.
Abreviations: Adjusted inspiratory flow, IFA (L/sec); Measured
inspiratory flow, IFM (L/sec); Inspiratory proximal pressure, IPP
(cmH2O); Inspiratory resistance, IR (cmH2O/L/sec); Adjusted
expiratory flow, EFA (L/sec); Measured expiratory flow, EFM (L/sec);
Expiratory proximal pressure, EPP (cmH2O); Expiratory resistance, ER
(cmH2O/L/sec).
DISCUSSION: VarFlex measured resistance is almost constant for GF
rate between 0.25 to 0.5 L/sec, but is near double for 1 L/sec GF.
Resistance values are not significantly different (p>0.05) for both
senses (inspiratory-expiratory). Resistance values for low to mean GF
are almost negligible for clinical measurements. Nevertheless, for
clinical investigations, resistance to high flows are to be considered
because they reach 50% of normal airway resistance.
2003; 96; S-1–S-293 S-147
S-146
THE EFFECTS OF PNEUMOPERITONEUM AND POSITION Reference:
CHANGES ON INTRAOCULAR PRESSURE 1) Effect of changes in PCO2 and body position on intraocular pressure
during general anaesthesia. Acta Ophthalmologica 1981;59:465-75.
AUTHORS: S. Demiroluk1, z. salihoglu2, O. Demirkiran1, Y. Kose1
AFFILIATION: 1Istanbul universitesi, cerrahpasa tip fakultesi, Periods 1 2 3 4 5 6
Istanbul, Turkey, 2Istanbul university, cerrahpasa tip fakultesi, Istanbul, MAP(mmHg) 97.56 84.52 111.2 112 112 95.18
Turkey.
HR (beat/min) 82.96 79.1 77.12 78.76 78.26 72.56
INTRODUCTION: During laparoscopy increased intraperitoneal IOP(mmHg) 16.41 14.11 14.67 16.75 14.78 14.42
pressure could cause physiological changes that affect intra ocular PIP(mmHg) 19.38 24.01 25.48 23.3 19.82
pressure (IOP) (1). The aim of our study is to investigate the changes in
IOP and its relationship with peak inspiratory pressure (PIP) and EtCO2(mmHg) 26.74 29.26 30.62 30.9 28.22
position changes during pneumoperitonium.
METHODS: ASA I-II, 50 patients (aged 42.46±12.8 years) undergoing
laparoscopic cholecystectomy were included to our study after approval
from the ethics committee of our institute. Anesthesia was induced with
propofol 2 mg/kg and fentanyl 2 mgr/kg . All patients were intubated
after receiving atracurium 0.5 mg/kg and ventilated mechanically with
frequence:12/dk and tidal volum:8 ml kg–1. Ventilation parameters
were kept constant throughout the study. Anaesthesia was maintained
with isoflurane %1 vol and intraperitoneal insuflation of CO2 was
maintained at 12 mmHg. Mean arterial pressure (MAP), heart rate
(HR), IOP (measured with shiötz tonometer, Germany), peak
inspiratory PIP and EtCO2 values were recorded: Before induction of
anaesthesia (1), before pneumoperitoneum (2), in the horizontal
position after the pneumoperitoneum (3), with a 150 head down tilt (4),
with a 150 head up position(5) and just before the extubation(6). Data
were analysed using repeated measures ANOVA with Tukey Kramer
test. P value smaller than <0.05 were considered statistically significant.
RESULTS: IOP, MAP and HR were decreased with the effect of
anaesthesia. While PIP, EtCO2 and MAP values showed a continual
increase with establishment of pneumoperitoneum, an increase in IOP
was only associated with the head down position and never exceeded
preinduction levels (table 1).
DISCUSSION: Although IOP is influenced minimally from the
pneumoperitoneum in deep anaesthesia, a special care should be taken
with head down position.
S-147
DOES NASAL CAPNOGRAPHY IMPROVE PATIENT SAFETY regression analysis was used to examine potential moderators of apnea.
DURING MAC? RESULTS: Ten (26%) of 39 patients experienced apnea, which were
reliably detected by capnography. In only one case did SpO2 decrease
AUTHORS: R. G. Soto1, E. S. Fu1, H. Vila Jr.2, R. V. Miguel1 below 90%. Average SpO2 of patients during apnea was 92±6%. There
AFFILIATION: 1University of South Florida, Tampa, FL, 2H. Lee were no changes in variables reflecting cardiovascular function during
Moffitt Cancer Center and Research Institute / University of South apnea. Anesthesia provider detected no episodes of apnea. Mean time to
Florida, Tampa, FL. apnea was 15±14min after onset of sedation. Variables reflecting
cardiovascular function were statistically equivalent throughout study
INTRODUCTION: Detection of apnea or airway obstruction is (Table: *P<0.05 v. Baseline; +P<.05 v. 0 L/min). Oxygenation and
essential when potent sedatives are employed. Pulse oximetry, routinely PETCO2 varied with oxygen flow rate. No independent variables
used during monitored anesthesia care (MAC), is a reliable estimate of predicted apnea.
arterial blood oxygenation; however, detection of apnea or airway DISCUSSION: Currently, capnography is not a mandatory ASA
obstruction can be delayed, especially if patients are breathing standard monitor for MAC procedures. This pilot study discovered
supplemental oxygen.1 Reliability of nasal capnography to monitor apnea of at least 20s is relatively common during MAC, which was
apnea and airway obstruction has not been examined in MAC/sedated undetected with routine monitoring. By design, we only studied apnea
patients breathing with and without supplemental oxygen. episodes lasting 20s. Unrecognized episodes of much greater duration
METHODS: Patients scheduled to undergo procedures with monitored can occur without capnography, resulting in patient compromise.
anesthesia care/sedation were studied after signing an IRB approved Technological improvements in measurement of end-tidal CO2 may be
consent form. A cannula designed to administer nasal oxygen and important in improving safety in patients undergoing sedation.
sample both nasal and oral carbon dioxide (Smart CapnoLineTMO2, REFERENCES:
Oridion) was appropriately positioned to measure PETCO2 with a 1. Anesth Analg 1999;88:S39.
handheld capnometer (NPB-70, Nellcor). Transthoracic impedance
monitoring (970S, Respironics) was used to measure respiratory rate. Supplemental O2 Flow Rate
Anesthesia provider had discretion regarding sedation regimen and Variables Baseline
(L / min)
employed monitors according to ASA practice guidelines for MAC, but
was blinded to capnography and impedance data. Oxygen flow through 0 2 4 6
nasal cannula was randomized at 0, 2, 4, and 6 L/min for 3min at each Episodes of Apnea NA 2 4 3 1
flow rate trial, with a repeat of randomized sequence every 12min. Data
were collected at baseline, while patients breathed room air before SpO2 (%) 97±2 97±2 98±2* 99±2* 99±3*+
sedation, and end of each trial until MAC was discontinued or apnea PetCO2 (mmHg) 42±10 45±10 43±12 38±13 36±14*
occurred. Apnea or airway obstruction for 20s, detected using
Respiratory Rate (/min) 19±4 16±5 19±6 17±5 16±6
transthoracic impedance monitoring, triggered an event. If apnea was
undetected by routine monitoring, anesthesia provider was notified and Heart Rate (/min) 77±10 78±13 78±15 77±12 77±13
patient was asked to breathe. If capnography did not detect apnea Mean Arterial Pressure (mmHg) 95±24 96±16 96±20 96±17 97±16
coincident with impedance monitor, position and patency of cannula
and capnometer were checked. Data were summarized as percentage or
mean±SD. Continuous data were compared with RM-ANOVA. Logistic
S-149 2003; 96; S-1–S-293
S-148
OCCUPATIONAL EXPOSURE TO SEVOFLURANE:
ASSESSMENT IN EXHALED BREATH
AUTHORS: P. Lirk, G. Summer, F. Bodrogi, J. Rieder, W.
Schobersberger
AFFILIATION: Dept. of Anesthesiology and Critical Care Medicine,
Innsbruck, Austria.
INTRODUCTION: Evidence on potential health hazards arising from
exposure to volatile anesthetics remains controversial. National public
health authorities have implemented threshold values to minimise
occupational exposure (1). Exposure may, in principle, be supervised by
monitoring of ambient air or, alternatively, in vivo measurements (2).
No investigations into volatile anesthetic kinetics in exhaled air of
occupationally exposed persons have been conducted.
METHODS: Proton Transfer Reaction-Mass Spectrometry (PTR-MS)
was employed to screen the breath of 10 OR staff members before OR
duty, 0, 1, 2, and 3 hours after duty, and before commencing duty on the
consecutive day. 15 persons not exposed to waste anesthetic gases were
enrolled as controls.
RESULTS: Staff members exhibited significantly raised sevoflurane
levels in exhaled air after duty, featuring a mean of 0.96 parts per billion
(ppbv) as compared to baseline values of 0.23 ppbv (p<0.05). At all
times, OR staff had exhaled sevoflurane levels greater than those of
control persons (p < 0.001). Patterns of sevoflurane decay in exhaled air
were depicted.
DISCUSSION: Using Proton Transfer Reaction-Mass Spectrometry,
sevoflurane concentration patterns in exhaled air of operating room staff
could be demonstrated. Exhaled air analysis may prove useful in short-
term monitoring of occupational exposure and the excretion of volatile
anesthetics.
REFERENCES
(1) Sister chromatid exchange in human lymphocytes exposed to
isoflurane and nitrous oxide in vitro. Br J Anaesth 1999; 82: 268-270
(2) Biomonitoring of exposure to nitrous oxide, sevoflurane, isoflurane
and halothane by automated GC/MS headspace urinalysis. Int Arch
Occup Environ Health 2001; 74: 541-548
S-149
THE COMPARISON OF DIFFERENT CALIBRATION polynomial compared to linear and conductance methods (p<0.05). For
METHODS FOR PNEUMOTACHOGRAPH the 2nd and 3rd order polynomial methods the volumes are as accurate
with 10 calibration strokes as with 50 calibration strokes, with average
AUTHORS: Y. Tang, J. S. Yem, M. J. Turner, B. A. Baker volume errors from 0.0000006% to 0.00032% and from 0.000069% to –
AFFILIATION: Department of Anaesthesia, Royal Prince Alfred 0.0000349%, respectively in the calibration groups and from
Hospital, Sydney Universtiy, Sydney, Australia. 0.009671% to 0.0016565% and from 0.01436% to 0.001014%,
respectively in the validation groups.
INTRODUCTION: The pneumotachograph generates differential DISCUSSION: Our study shows that the second and third order
pressure approximately proportional to the flow and viscosity of the polynomial methods produce the best results for the calibration of a
gas. As the viscosity varies with the gas composition, temperature, and screen pneumotachograph, with a volume error as low as 0.009671%.
humidity, flow-to-pressure conversion of a PT depends on all these Using 10 calibration strokes, we achieved similar accuracy as 50 strokes
factors. This report describes a new method for determining polynomial with second and third order polynomial methods. Second and third
calibration curves from a number of syringe strokes and compares this order polynomial methods are more accurate and efficient than either
new method with the conductance array method1 of calibration. conductance or linear regression methods for the calibration of
METHODS: The experimental apparatus includes a 3-litre precision pneumotachograph.
syringe, a screen pneumotachograph, a differential pressure transducer, REFERENCE:
a voltage carrier demodulator, a 6th order linear phase low pass filter, 1. Yeh, M.P. et al. J Appl Physiol 1982;53:280-285.
and a pressure transducer. With each syringe stroke, the differential
pressure signals were recorded through a 12-bit analog to digital
converter at the rate of 325Hz. The calibration and validation procedure
consisted of 50 calibration and 70 validation strokes respectively. The
volume of each stroke was evaluated by numerical integration. The
Matlab optimization toolbox was used to obtain a parameter set that
minimized volume errors for each polynomial. The conductance values
were calculated using a Yeh’s procedure1. Starting from a constant
conductance for each stroke, the conductance values were updated
using a weighted-averaging technique. The volume errors for the same
set of calibration strokes and validation stokes were calculated using
those conductance values and polynomial parameters.
RESULTS: Differences between conductance, linear, 2nd and 3rd
order polynomial calibration curves and linear curve are plotted against
differential pressure in Fig 1. When the coefficients are derived from
calibration strokes and apply to the same set of strokes, the differences
of the mean volume errors of the four methods are not significant, but
variance was bigger for the linear group (p<0.05). When a separate set
of 70 validation syringe strokes were used to assess the calibration
curves, the volume errors were the smallest for 2nd and 3rd order
2003; 96; S-1–S-293 S-151
S-150
COMPARING ECGS GENERATED FROM A NOVEL rater out of three were unable to read the rate, rhythm, and QRS (7.4) or
STERNAL DEVICE TO TRACINGS PRODUCED BY THE none of the raters could read the rate, rhythm, or QRS on a single
BACKPAD ECG AND A STANDARD THREE LEAD ECG patient (2.1). (note: the sternal ECG received a score of 6.75 in one
patient).
AUTHORS: J. R. Schultz, H. A. Muir, J. Greenfield, B. Phillips-Bute, DISCUSSION: As Einthoven‘s triangle is traditionally thought of as a
W. White, J. Reynolds large triangle over the chest wall, this study suggests that shrinking
AFFILIATION: Duke University Medical Center, Durham, NC. Einthoven‘s triangle may have practical applications in anesthesiology,
such as using a sternal ECG. The descriptive statistics suggest the
INTRODUCTION: When placing electrodes to generate an sternal ECG and Backpad, while they simplify use, do not appear to
electrocardiogram (ECG) recording, Einthoven‘s triangle is typically compromise the quality of the ECG tracing. Continued investigation is
thought of as a large area over the chest wall. There is no evidence to warranted to increase the power of the study and determine if the sternal
suggest shrinking the triangle to a region just over the heart itself would ECG pad can pick up evidence of myocardial ischemia or potential
compromise the quality of the ECG tracings. Such a reduction would dysrrhythmias.
aid wire placement and ECG attachment using a single ECG pad
(sternal pad). To assess the viability of this approach, we designed a Total Affirmative Responses (3 evaluators rate 3 ECG methods on 10 patients)
sternal ECG pad and compared ECG tracings generated by a standard (n=30) QRS Rate Rhythm
electrode setup and to those produced by the Backpad ECG, a single
peel-off ECG pad placed on the back. 1-Standard ECG 30/30 30/30 30/30
METHODS: The sternal ECG pad was designed by the PI and 2-Backpad 30/30 30/30 29/30
produced by ConMed® corporation of Utica, NY that also designed the 3-Sternal ECG 30/30 29/30 28/30
Backpad ECG pad. Our pad consists of three leads positioned one inch
apart forming an equilateral triangle. All three leads are contained in a
small pad with a single peel-off sticker. This sternal ECG allows for
easy placement and simplifies set-up, removal, monitoring, and re-
attachment. After IRB approval, written consent was obtained from
ASA I and II patients presenting for routine surgical procedures. After
induction of anesthesia, standard, Backpad, and sternal ECG tracings
were recorded successively. Each ECG tracing was read by three
anesthesiologists unaware of the device used to generate the recording.
The strips were evaluated for rate, rhythm, p wave, QRS, and t wave (10
patients). A weighted scale was developed for each of the five ECG
components. Rate and rhythm were given a weight of 1, and .95
respectively. The QRS was weighted .7, p-wave .5, and t wave .2.
RESULTS: We describe the results of our pilot project. The means and
standard deviations for the weighted score are: sternal ECG 9.2 (1.2),
Back-pad 9.8 (0.74), and standard ECG 10 (0.16). We consider a score
of 7.5 or less to be clinically unacceptable which would occur if one
S-151
RELIABILITY FOR ASSESSMENT OF HEPATIC FUNCTION k is the elimination constant, Cd (t) and Cd (0) are the blood
USING ICG PULSE DYE DENSITOMETRY DURING HEPATIC concentration of ICG at time t and 0, and Cdr is the residual ICG
TRANSPLANTATION concentration at time 0. The effects of residual ICG (1- 20 % of the initial
concentration) on the K values (0.05-0.2) were simulated. All simulations
AUTHORS: I. Uchida1, N. Kobayashi2, T. Usuda3 were performed
AFFILIATION: 1Osaka University Medical School, Suita, Japan, RESULTS: (1) The ICG concentrations measured by PDD were 5.2, 3.6
2
Nihon Kohden Corporation, Saitama, Japan, 3Kohden Corporation, and 11.8% at 10, 20 and 30 mg/dL of bilirubin, respectively, lower than
Saitama, Japan. those in the absence of bilirubin. (2) In the range of 0.05 and 0.2 on K, the
error for K was less than 0.02 when more than 30min interval for
The Indocyanine green (ICG) elimination test is a reliable indicator for measurement is allowed.
the liver function. Pulse dye densitometry (PDD) is based on the principal CONCLUSION: Since K value calculated from the elimination curve is
of pulse spectrophotometry and can measure the blood concentration of little affected by high bilirubin concentration, PDD is reliable monitor for
ICG continuously after its administration. The PDD can provide the ICGK in severe hepatic dysfunction.
measurement of blood volume and cardiac output as well as the ICG
elimination rate. Then the effective hepatic blood flow is simultaneously
estimated by the values of blood volume and ICG elimination rate
constant (ICGK). Therefore the measurements of ICGK could be a simple,
noninvasive and reliable method to monitor the liver function during
hepatic transplant (figure). However the reliability for measurement of
the PDD in the patient with the severe liver dysfunction has not been
established. In this study, we simulated the effects of bilirubin and
residual ICG on the values of ICG and ICGK calculated by the PDD using
the computer.
METHODS: (1) The ICG concentrations (12: the ratio of optical
densities) corrected by bilirubin values in measurement of the PDD can
be expressed by the following equation based on the Lambert-Beer’s law
and Schuster’s: 12 = [{(Eh1+Ed1Cd/Hb+Eb1Bil/Hb)(Eh1+Ed1Cd/
Hb+Eb1Bil/Hb+F)} - EX1] / [{(Eh2+Eb2Bil/Hb)(Eh2+Eb2Bil/Hb+F)} -
EX2], where Eb is absorption coefficient of hemoglobin, Ed is absorption
coefficient of ICG, Hb is concentration of hemoglobin, Cd is
concentration of ICG, F is scattering coefficient, Ex is tissue constant,
suffix1 is 805nm, suffix2 is 940nm, Eb is absorption coefficient of
bilirubin, and Bil is concentration of bilirubin. Using this equation the
effects of bilirubin in the range from 0 to 30 mg/dl on ICG concentrations
were simulated at constant Hb level(14g/dl Hb). (2) The blood
concentration time course of ICG were fitted to the following equation
based on one-compartment model: Cd (t) = {Cdr + Cd (0)} • e - Kt , where
S-153 2003; 96; S-1–S-293
S-152
ACCURACY OF NEEDLELESS SYSTEMS IN INTRAVENOUS significantly increased the actual delivered dose.
ADMINISTRATION OF SMALL VOLUME DRUGS TO DISCUSSION: The Bloodborne Pathogens Standard of the
INFANTS AND CHILDREN Occupational Safety and Health Administration (OSHA) mandates the
use of safer needlestick devices nationwide. Access sites for medication
AUTHORS: S. T. Verghese, R. S. Hannallah, S. Soldin administration should be needleless, maintain sterility during multiple
AFFILIATION: Children's National Medical Center, Washington, DC. uses, and prevent leakage or backflow.
Although syringe/needle/tubing technology has been touted as simple
INTRODUCTION: Health care workers sustain 600,000 to one and intuitive, it is a known cause of personnel and sometimes patient
million needle-sticks per year, resulting in at least 1,000 new cases of injury. The valved needleless system is an acceptable alternative for
HIV, hepatitis C, or hepatitis B. More than 80% of needlestick injuries delivering small volumes of injected drugs. It is recommended that a
can be prevented through the use of safe devices. These include the use separate syringe, not containing traces of the injected drug, be used for
of stopcocks or valved injection ports (e.g. the Clave or SmartSite flushing. When using a stopcock for bolus dosing, a dilution of the
systems) for IV drug injections. Although the internal dead space of intended dose to a minimal volume of 0.5 ml, followed by flushing, will
these devices is small, it can result in major inaccuracies when small ensure accurate dosing.
volumes of drugs are injected; as typically happens in infants and small
children. This study compared the accuracy of two needleless systems
against the "gold standard" of a needle system when a small volume of
IV drug is injected.
METHODS: A simulated clinical situation was created by injecting
five different volumes of a standard 50% dextrose solution (0.1, 0.25,
0.5, 1 and 3 ml) into a running IV line delivering a measured 100 ml
volume of distilled water into a measuring cup. The injections were
performed using a 23-gauge needle into the side port of the IV tubing,
into a stopcock, and into a valved needleless side port (Clave). All
injections were again repeated with the injection site flushed after drug
administration with a 1-ml volume of water. The difference between the
measured dextrose concentration and the expected concentration in
each 100-ml sample was determined. A difference of over 25% was
considered unacceptable.
RESULTS: When very small volumes (0.1 and 0.25 ml) of "drugs"
were injected, the needle system was consistently accurate. Injection
through a stopcock was the least accurate, especially when no flushing
was employed. The valved needleless Clave system delivered accuracy
close to that of a needle, especially with flushing. The technique of
flushing had a considerable effect on the ultimate amount of drug
injected. If flushing is performed using the same syringe that delivered
the drug, the additional trace of drug that is contained in the dead space
S-153
DELIVERY OF NORMOTHERMIC BLOOD AND FLUIDS TO slower warm-up time of the heater. With the units assembled and warm
PEDIATRIC PATIENTS USING A DRY HEAT WARMER for 15 minutes, Ranger took 42 seconds to deliver normothermic packed
cells while Hotline took 26 seconds. At flows greater than 60ml/min,
AUTHORS: P. E. Horowitz, J. Thomas, R. G. Soto Hotline did not deliver 37°C packed cells.
AFFILIATION: Univ. of South Florida, Tampa, FL. DISCUSSION: We have demonstrated that the dry heat blood/fluid
warmer, Ranger, can be configured for rapid infusing of normothermic
INTRODUCTION: The disposable insert for the dry heat blood/fluid blood and fluids to pediatric patients and reducing the potential for
warmer, Ranger (Augustine Medical), can be distended with an hypothermia and bradycardia. The initial setup time to deliver aliquots
additional 20ml bolus injection. Using a to-and-fro manual injection of normothermic fluids is significantly faster with Ranger. Hotline is
into the Ranger, we have utilized this distensability and warmed 10-15 faster for subsequent normothermic deliveries but this difference is not
ml volumes of cold (10°C) packed cells to 37°C to be used for rapid clinically significant.
delivery to pediatric patients. We compared the speed and ease of REFERENCES:
preparation of 37°C volumes using our method with one previously 1. Can J Anaesth 1998; 45: 1110-3
described using the water bath warmer, Hotline (SIMS Level 1).1
METHODS: We recorded the time it took to turn on the heater,
assemble the disposable components, wait for each heating unit to read
40°C and have each system deliver a 10-15 ml volume of 10°C packed
cells warmed to 37°C. We also recorded the delivery time for
subsequent normothermic aliquots. For Ranger, we used a blood
administration set, a 20 ml syringe and a 3-way stopcock attached to the
inflow tubing of a standard disposable warming set with a thermistor
inserted into the inflow line. After 10°C packed cells flowed through
the blood administration tubing, stopcock and disposable warming set,
the outflow tubing was clamped off when blood began to exit the
warming unit. Additional blood (15-20ml) was withdrawn from the
blood bag into the syringe and then manually injected and withdrawn
from the warming unit until the packed cells had been warmed to 37°C.
For Hotline, we used blood tubing with a stopcock and 20ml syringe at
each end of the disposable warming set. Once the heating unit reached
40°C, packed cells (10°C) were injected into the warming system and
collected in a syringe after passage through an inline thermistor. Time to
availability of 37°C packed cells was also recorded after each
assembled system remained on for 15 minutes. Measurements were
taken twice for each system and results were averaged.
RESULTS: It took 4.2 minutes for Ranger (measured from turning on
the heater and including 7-8 to-and-fro injections) to produce 10-15ml
of 37°C packed cells. It took 12.5 minutes for Hotline, mostly due to the
2003; 96; S-1–S-293 S-155
S-154
DO VARYING LEAD LEVELS INTERFERE WITH in ranges commonly encountered among industrially exposed
COAGULATION: AN IN VITRO THROBELASTOGRAPHY populations, based on in vitro TEG MA values.
(TEG) STUDY WITH WHOLE BLOOD REFERENCES:
1. Bulleova S, Rothenberg SJ, Manalo MA. Lead levels in blood bank
AUTHORS: K. Lewis1, G. Dinkins1, J. McQuirter1, S. J. Rothenberg2, blood. Archives of environmental health 2001; 56:312-313.
M. Manalo3, J. S. Jahr4 2. Jahr JS, Lurie F, Gosselin R, Lin JS, Wong L, Larkin E. Effects of a
AFFILIATION: 1King/Drew Medical Center, Los Angeles, CA, Hemoglobin-based Oxygen Carrier (HBOC-201) on coagulation
2
National Institute of Public Health, Cuernavaca, Mexico, 3Charles R. testing. Clin Lab Sci 2000;13:210-214.
Drew University of Medicine and Science, Los Angeles, CA, 4UCLA
TEG MA Values at Increasing Lead Levels (N = 4, [plusminus] SEM)
School of Medicine, Los Angeles, CA.
LEAD
1.8 mcg/dL 11.1 mcg/dL 20.3 mcg/dL 47.4 mcg/dL 65.9 mcg/dL
INTRODUCTION: Lead levels in the toxic range have been noted in 2 CONCENTRATION
of 1000 units of blood bank blood (1). We compared coagulation MA(mm) 69.6±3.7 63.4±1.1 57.0±3.7 48.5±3.9 49.3±4.3
parameters using a TEG on whole blood with differing levels of added
lead. Hemoglobin-based Oxygen Carriers have been tested for
coagulation in conventional laboratory equipment by our team (2).
METHODS: Three mL of remainder sample blood was tested from 4
individuals and placed in a 3 mL blue top Vacutainer (Heparin).
Baseline blood lead was measured in each sample using Zeeman-
corrected atomic absorption spectrometry with graphite furnace. Prior
to testing for each TEG, Heparinase, in the concentration used for
routine TEG analysis, was used to reverse the heparin effect. Baseline
TEG values (r, k, alpha angle, MA, EPL) and lead levels were
measured. Then lead acetate was micropipetted into the TEG cuvette to
produce the following lead concentrations (assuming baseline lead
levels of 0): 10, 20, 50, and 70 µg/dL. A TEG was immediately
performed. Blood lead levels were measured in each sample after
addition of lead acetate. The effect of lead level on TEG variables was
compared using an analysis of variance (ANOVA) for repeated
measures.
RESULTS: Four blood samples were obtained for this study. See Table
for data from five TEG assessments at different lead levels. With
increasing lead in the blood, MA significantly decreased (p<0.02).
Mean MA decreased from 69.6 mm at baseline to 48.5 mm (p=0.035) at
a nominal blood lead level of 50 µg/dL.
CONCLUSION: The effect of lead exposure on platelet function has
been unexplored. Our results suggest that lead worsens platelet function
S-155
ELECTRONMICROSCOPIC EVALUATION OF CLOT
FORMATION ON THROMBOELASTOGRAM
AUTHORS: J. Kawasaki1, K. A. Tanaka2, H. Takei1, T. Maruo1, H.
Miyao1
AFFILIATION: 1Saitama Medical School, Kawagoe, Japan, 2Emory
University, Atlanta, GA.
INTRODUCTION: Thromboelastogram (TEG) is a clinically useful
coagulation monitor to guide transfusion of hemostatic products. Clot
forms after activation of fibrin and platelets, but the exact sequence of
TEG events has not been clearly described. We attempted to
characterize the morphology of forming clot with scanning
electronmicroscopy (SEMS).
METHODS: After institutional approval, blood samples were obtained
from 6 healthy volunteers. 2-channel TEG (CTEG-3000T,
Haemoscope, Niles, IL) was performed using 330 mcL recalcified
blood samples (20 mcL of 0.2 M CaCl2). First channel was used to
obtain TEG variables: reaction time (R); amplitude; A 10 mm, A 20
mm, A 30 mm, maximum amplitude (MA), and second channel was
used to obtain sub-samples for morphological examination by SEMS.
Abciximab-modified TEG was also studied using c3E7 (Centocor) at
final concentration (25 mcg/mL).
RESULTS: SEM images are shown in figures (A-F). At R point, coarse
fibrin and budding of platelets are seen (fig. A). At A10 point, platelet
shape change is observed (fig. B). At A20, fibrin strands are more
clearly seen, and RBCs are somewhat bundled in-between fibrins and
deformed (fig. C). At A30 point, RBCs are surrounded with thick mesh
of fibrin strands (fig. D). At MA point, RBCs are squeezed together by
fibrins (fig. E). With addition of abciximab, RBC shapes are still
maintained at MA point (fig. F).
DISCUSSION: Our morphological evaluation of TEG agrees with
conventional theory regarding TEG tracing, i.e., the amplitude of TEG
reflects fibrin formation and platelet activation. Because RBCs are
interspaced between forming fibrin and platelet bonds, hematocrit value
may affect TEG results.
S-157 2003; 96; S-1–S-293
S-156
EFFECT OF HEAD POSITION ON CORMACK SCALE worsened glottic exposure as compared to the sniffing position in 39%
GRADING DURING LARYNGOSCOPY: IS ‘SNIFFING cases (p<0.002) and did not alter laryngosopic exposure in 51% cases.
POSITION’ THE BEST? There was no difference in exposure between flexed and extended
positions in 53% cases, while in 37% cases flexion position worsened
AUTHORS: F. Chen, C. Chia, C. Tham exposure as compared to extension position (p<0.006).
AFFILIATION: Department of Anaesthesia, National University DISCUSSIONS: Routine use of sniffing position does not appear to
Hospital, Singapore, Singapore. offer any significant advantage over simple neck extension for tracheal
intubation. However, neck flexion significantly worsens laryngoscopic
INTRODUCTION: Traditionally, 'sniffing position' is recommended visualization of vocal cords.
during direct laryngoscopy. Recently, Adnet et al found the 'sniffing REFERENCES:
position' not superior to simple neck extension in their group of patients 1. Adnet F, Baillard C, Borron SW et al. Randomized study comparing
sedated with propofol.1 Hochman et al found on the other hand the the "sniffing position" with simple head extension for laryngoscopic
flexion position provided the best glottic exposure.2 Our aim in this view in elective surgery patients. Anesthesiology. 2001; 95:836-41.
study is to determine if the 'sniffing position' provides superior 2. Hochman II, Zeitels SM, Heaton JT. Analysis of the forces and
laryngoscopic visualisation of the glottis compared to neck extension position required for direct laryngoscopic exposure of the anterior vocal
and flexion in elective anaesthetized paralysed patients. cords. Ann Otol Rhino Laryngol 1999; 108: 715-24.
METHODS: This was a randomized controlled prospective trial
involving 51 adult patients of ASA class 1 or 2 scheduled for elective
surgery in which general anaesthesia with IPPV was required.
Exclusion criteria were patients at risk of aspiration or had conditions
contraindicating intubation. After induction and paralysis, each patient
was placed in the three intubating positions. The sniffing position was
obtained by placement of a 7-cm pillow under the patient‘s head. The
extension position was obtained by simple head extension while the
flexion position had the patient's neck flexed to approximately 30
degrees by one of the investigators. Direct laryngoscopy was then
performed by an independent observer at all 3 positions, and the
laryngoscopic view was assessed using the Cormack scale without
application of external laryngeal pressure.
RESULTS: The mean age was 39.8 ± 14 years while the mean inter-
incisor and thyromental distances were 4.4 ± 0.8 cm and 6.0 ± 1.2 cm
respectively. Median Mallampati score was 2. While median Cormack
grading was 2 for all 3 positions, there were more patients with grade 1
exposure during sniffing and neck extension positions (22 and 23
patients respectively) as compared to flexion position (11 patients).
There was no significant difference (p<0.8) in laryngoscopic view
between the sniffing and extension positions while flexion position
S-157
AN EVALUATION OF ENDOTRACHEAL INTUBATION REFERENCES:
USING THE MACINTOSH VIDEO LARYNGOSCOPE 1. Weiss M. Video-intuboscopy. A new aid to routine and difficult
tracheal intubation. Br J Anaesth 1988; 80:525-7.
AUTHORS: C. A. Hagberg1, D. G. Iannucci1, A. L. Goodrich2 2. Weiss M, Schwarz U, Diller C, Gerber AC. Video-intuboscopic
AFFILIATION: 1University of Texas-Houston Medical School, monitoring of tracheal intubation in pediatric patients. Can J Anaesth
Houston, TX, 2Rice University, Houston, TX. 2000; 47:1202-6.
INTRODUCTION: The Macintosh Video Laryngoscope (MVL) is
designed to optimize visualization of the airway by projecting an enlarged
video image of the laryngeal structures onto a monitor.1,2 This study was
designed to assess the effectiveness of the MVL by comparing the view
of the glottic opening obtained with the (1) naked eye and (2) video
monitor.
METHODS: This study was conducted on 102 anesthetized, paralyzed,
apneic patients, ranging in age from 18-80, with no known abnormalities
of the upper airway. Observations of the laryngeal structures were made
by both a direct view of the oropharynx, and an image projected onto a
video monitor using a size 3 MVL. Observations were categorized into
the following classifications: full view of glottic opening (Grade I), partial
view of glottic opening (Grade IIa), posterior portion of cords (Grade IIb),
epiglottis only (Grade III), and neither epiglottis/glottis (Grade IV). The
necessity of external laryngeal pressure was determined, applied if
necessary, and optimal views again obtained.
RESULTS: The MVL displayed a Grade IIa or better classification in
99% of the patients (82% Grade I), in contrast to 52% of the patients
(35% Grade I) with the naked eye (Figure 1). Thirty-three patients were
thought to be possible difficult intubations. The possibility of a difficult
intubation was noted when one or more of the following conditions were
present: small mouth opening (<3 fingerbreadths), limited neck mobility,
or a Mallampati III classification. Of these patients, the MVL revealed a
Grade IIa or better classification in 97% (67% Grade I) on the monitor,
compared to 3% (0% Grade I) with the naked eye.
DISCUSSION: The view on the video monitor provided a superior view
of the laryngeal structures in comparison to the view obtained with the
naked eye using the MVL. This study suggests that the MVL may be a
practical device to aid in difficult intubation, yet further studies are
warranted in this area.
2003; 96; S-1–S-293 S-159
S-158
A PROSPECTIVE, RANDOMIZED, CROSSOVER STUDY TO and the tube position was confirmed by capnography. The success rates
ASSESS THE ENDOTRACHEAL TUBE CUFF INFLATION AS and attempts with cuff-inflation and cuff-deflation were compared using
A MEANS OF IMPROVING SUCCESS RATE OF BLIND the 2 test, and the time taken by unpaired t-test (P<0.05=significant).
NASOTRACHEAL INTUBATION (BNI) UNDER VARIOUS RESULTS:
CONDITIONS.
CUFF INFLATED / DEFLATED
AUTHORS: R. Kumar1, M. Sethi2, R. Sehgal2, V. K. Bhatia3 Operator Trainee Trained
AFFILIATION: 1Maulana Azad Medical College, New Delhi-110
002, INDIA, Delhi, India, 2Maulana Azad Medical College, Delhi, Patient Apneic Breathing Apneic Breathing
India, 3IASR Institute, New Delhi., Delhi, India. Success (%) 40/45 45/35 55/65 85/85
Success 29±16/ 43±24/ 38±18/ 31±24/
INTRODUCTION: Cuff inflation seems to facilitate the passage of
nasotracheal tube (NTT) during blind nasal intubation (BNI)1 in apneic time (sec) 60±47 56±53 59±32 39±21
and spontaneously breathing patients2-4 even in unskilled hands.5 We Attempts for success
1.1±0.4/ 2±0.9/ 1.5±0.7/ 1.5±0.7/
hypothesized that the technique will be useful only for a beginner and 1.8±0.8 1.7±1 1.8±0.8 1.5±0.6
not for a trained anesthesiologist. Failure 69±34/ 105±66/ 69±31/ 67±14/
METHODS: After IRB approval, this study was conducted in 80 ASA
I/II patients aged 16years. Patients were randomized into apneic and time (sec) 127±41* 137±46 119±81 168±14#
breathing groups (n=40 each), then into trained and trainee subgroups Data as mean±SD. *P=0.014; #P=0.027 (Cuff Inflated v/s Deflated)
(n=20 each) and finally to crossover between cuff-inflation first (CI) or DISCUSSION: Cuff inflation does not improve the success rate of BNI
cuff-deflation first (CD) (n=10 each). Patients' nostrils were for trained or trainee anesthesiologist. Although it lifts the tube away
decongested and they were premedicated with i.v. atropine 0.6mg, from the posterior pharyngeal wall, it probably pushes the tip more
meperidine 0.5mg.kg-1, and diazepam 5.0mg 15min before induction of anteriorly than required in some cases and does not centralize it with
anesthesia with i.v. thiopental 5mg.kg-1 and N2O 66% and halothane in respect to the lateral pharyngeal walls. However, it may be tried ahead
oxygen. The apneic-group patients received vecuronium 0.1mg.kg-1 i.v. of the usual BNI because, with similar success rates, the average time in
The NTT (Mallinkrodt®) was introduced into the lubricated nostril and cases of failure is consistently less (significantly so under two
pushed to the nasopharynx and then further with either cuff deflated or scenarios) than with cuff deflated.
inflated (with 15ml air till resistance was felt, when the cuff was REFERENCES:
deflated). Whenever it was felt that the tube had entered the trachea, its 1. Anesth Analg, 1987;66:917.
position was checked by laryngoscopy. In case the intubation failed, 2. Anesth Analg, 1998;87:400-2.
more attempts (maximum=3) were made. After intubation/failure by the 3. Anesthesiology, 1992;77(3):613-4.
first method, the patient's condition was stabilized and the second 4. Br J Anaesth, 1993;71:772-3.
method attempted. When the trachea was intubated by the second 5. Br J Anaesth, 1993;70:691-4.
method (or under vision if it failed), surgery was allowed to start. In
breathing-group patients airway was topicalized after induction of
anesthesia, the patients breathed spontaneously during the study period
S-159
WARNING SYSTEM TO DETECT CONTACT WITH UPPER *p= 0.142 comparing single versus > 1 signal; + p < 0.000 comparing
TEETH DURING LARYNGOSCOPY buzzer on / off
AUTHORS: R. S. Bolis, k. LeDez DISCUSSION: The modified laryngoscope appeared to successfully
AFFILIATION: Memorial University of Newfoundland, St.John's, NF, detect contact with the upper teeth. Persistent pressure occured only
once with the buzzer on, significanly less than when the buzzer was off.
Canada.
Repeated contact occured in 73.1% and 59.9% with the buzzer off and
INTRODUCTION:Damage to the teeth is the most common on respectively with these inexperienced personnel, but this did not
complication during laryngoscopy (1) with an incidence of 0.02% to reach significance at the 5% level. The system showed promise for
0.7% (2) future use in clinical trials.
METHODS:A size 3 Macintosh Laryngoscope blade was modified to REFERENCES:
incorporate a Force Sensing Resistor (FSR), connected by a wire to an (1) Anesthesia Intensive Care 2000; 28: 133-145.
integrated circuit that could activate a buzzer and two light-emitting (2) Endo Dent Traumatology 1999; 15: 33-36
diodes (LED). "Slight" pressure resulted in slow beeping and a yellow
flashing light (warning signal) and greater pressure faster beeping and a
red flashing light (crisis signal).
Ten intubations were performed on an training manikin by each of 21
Respiratory Therapy students and staff (RT) with a size 7 styletted
endotracheal tube. The buzzer was switched on in random order for half
the trials without the RT's knowledge. The signals (buzzer / light) per
intubation were recorded, with successful intubation confirmed by
inflating the lungs of the manikin using an Ambu bag. Data were
analyzed using Chi-Square.
RESULTS: 199 of 210 trials resulted in successful intubation (mean
time 12 sec. / intubation) with a contact signal (s) in 36.1%. Persistant
pressure was significantly more frequent with the buzzer off (p < 0.000)
[table 1]
Buzzer switch On Off
Number of trials with contact 35 (46%) 41 (53.9%)
Signal once / trial 14 (40%)* 11 (26.8%)
Signal twice / trial 12(34.2%)* 12 (29.2%)
Signals3 times or more / trial 9 (25.7%)* 18 (43.9%)
Total number of signals 69 105
Mean number of signals / trial 1.97 2.44
Number of warning signals 58 (84%) 66 (62.8%)
number of crisis signals 10 (14.4%) 19 (18%)
Number of signals with persistant pressure > 3 sec 1 (1.4%)+ 20 (19%)
S-161 2003; 96; S-1–S-293
S-160
A LABORATORY STUDY OF GAS DIFFUSION THROUGH AN RAMS quadrapole mass spectrometer (GE Marquette, Milwaukee, WI).
ELLIPTICAL CUFF OF A LARYGEAL MASK AIRWAY RESULTS: Nitrous oxide diffusion far exceeded the diffusion of
oxygen, which occurred faster than nitrogen. The volume of air used to
AUTHORS: A. Paulsen, K. Houchin inflate the cuff as well as the concentration difference between nitrous
AFFILIATION: Emory University, Atlanta, GA. oxide inside and outside of the cuff, and oxygen inside and outside of
the cuff, determines the magnitude of the pressure increase.The
INTRODUCTION: The purpose of this study was to examine basic permeability of each gas through the rubber and the initial cuff volume
gas diffusion properties of the elliptical cuff that is the mask component determines the time constant for the pressure change.
of the Laryngeal Mask Airway. Concern has been expressed that the use DISCUSSION: Because oxygen diffuses faster than nitrogen, 100%
of nitrous oxide will increase the pressure within the cuff and oxygen surrounding an LMA cuff filled with air produces an increase in
potentially result in hypoperfusion of tissue in the posterior cuff pressure, which like nitrous oxide, may also be of concern
hypopharynx. Through a better understanding of the diffusion clinically.This data supports the need to regularly monitor LMA cuff
properties of the rubber elliptical cuff, potential risks of using the LMA pressure even when nitrous oxide is not used.
may be minimized. REFERENCES:
METHODS: Laboratory studies were used to evaluate Laryngeal Mask Anaesthesia 47:320-323, 1992
Airways (The Laryngeal Mask Company, Ltd), sizes 3, 4 and 5 using Anaesthesia 48:1075-1078, 1993
simple binary and more complex trinary gas mixtures. The compliance Journal Clinical Anesthesia 8:93-98, 1996
curves of the cuff were obtained for each size LMA. At the start of data Anesthesiology 81:63-67, 1997
collection LMAs were placed in pieces of PVC pipe of the appropriate
size in order to simulate the constraints imposed on the cuff by the
placement in the patient's oropharynx. The table below demonstrates
the experimental protocol for each gas combination.
The gas volumes within the cuff were 30 ml, starting from a completely
deflated cuff volume, which mimics the clinical experience. Other
volumes (15ml, 20ml, and 40 ml) were investigated under specific
circumstances. Pressure in each cuff was recorded two times per second
for 90 minutes using Labtech Notebook software (Laboratory
Technologies, Andover, MA) running on a PC. At the end of 90
minutes, the gas concentrations within the cuffs were analyzed using the
S-161
MANUAL VENTILATION OF A PATIENT TURNED 180° induction, mechanical ventilation was observed for 20 minutes (test
AWAY FROM THE ANESTHESIA MACHINE BY A SINGLE period #1). Subsequently, the patient was manually ventilated using an
OPERATOR OMAR circuit for 10 minutes (test period #2). Ten minutes of
mechanical ventilation was again observed (test period #3), followed by
AUTHORS: L. F. Chu, K. Harrison, J. G. Brock-Utne 10 minutes of manual ventilation with the OMAR circuit (test period
AFFILIATION: Stanford University School of Medicine, Stanford, #4). During each testing period, end-tital CO2 (ETCO2), respiratory rate
CA. (RR), tidal volume (TV) and peak inspiratory pressures (PIP) were
recorded.
INTRODUCTION: At times the patient may be turned 180º away RESULTS: The mean ETCO2 among the four test periods (#1,
from the anesthetic machine and the anesthesiologist. We have used a 33.5±1.7; #2, 33.3±1.5; #3, 34.3±1.0; #4, 33.8±1.5) were not
modification of the OMAR slave1 (personal communication 1970, significantly different (P>0.3). The mean RR among the four test
Figure 1) which makes it possible, in the above circumstances, for one periods (#1, 6.5±0.5; #2, 8.3±0.5; #3, 6.5±0.6; #4, 8.3±0.5) were
operator to stand at the head of the operating table both controlling the significantly higher in the OMAR circuit (test periods #2 and #4)
airway and manually ventilating the lungs. (P<0.005). The mean tidal volumes among the four test periods periods
METHODS: OMAR Circuit Construction: Our modification of the (#1, 648±142; #2, 571±186; #3, 663±180; #4, 683±125) were not
OMAR slave consists of a Portex Straight Gas Sampling Connection significantly different (P>0.3). Finally, the PIP among the four groups
with a Luer port and cap2 placed where the breathing bag is situated on a (#1, 20.5±1.7; #2, 17.3±2.2; #3, 20.8±1.9; #4, 16±1.6) showed that they
Narcomed 2B anesthetic machine3. This is connected to approximately were significantly lower in the OMAR circuit (test periods #2 and #4)
8 feet of 22 mm diameter anesthetic tubing extending to the head of the (P<0.05).
table and fitted with a valve with a bleed vent from a Baby Safe DISCUSSION: Our results show that the OMAR circuit can be used by
Resuscitator4 (Fig 1). a single operator for manual ventilation of a patient turned 180º from
the anesthetic machine while maintaining minute ventilation and
ETCO2 compared to mechanical ventilation. We believe this device may
be useful to the lone anesthesiologist needing to control ventilation
from the head of the bed turned 180º from the anesthetic machine.
REFERENCES:
1) Personal communication, Dr. Omar, 1970
2) Sims Portex, Fort Meyers, FL 33905, USA
3) North American Drager, Telford, PN 18969
4) Vital Signs, Tolowa, NJ 07512
Study Design: 10 patients ages 30-67 (55 ± 25 years old) were randomly
selected to participate in the study. General anesthesia was induced and
maintained in the normal manner. Data were obtained during 4 testing
periods during general endotracheal anesthesia. 10-20 minutes after
2003; 96; S-1–S-293 S-163
S-162
ENDOTRACHEAL LIDOCAINE WITH DISPERSION STEAM anesthetic. This steam is introduced through the endotracheal tube,
FOR AWAKE EXTUBATION getting the distal end 3 centimeters under the tip tube (figure 1).
RESULTS: Demographic data were comparable between the two
AUTHORS: J. C. Kling1, O. Amaya2, F. R. Montes1, S. Pino1 groups. The incidence of coughing was 27% and 64% for DS group and
AFFILIATION: 1Fundacion Cardioinfantil - Instituto de Cardiologia, L group, respectively (P=0.001). Arterial blood pressure and heart rate
Bogota, Colombia, 2Fundacion Santa Fe, Bogota, Colombia. increased significantly in the L group (P < 0.001). There was no
difference in extubation time, patient recall or perception of discomfort
INTRODUCTION: The aspiration of gastric content inside the during the procedure.
tracheobronquial tree is a rare event during anesthesia. When it occurs, DISCUSSION: Our data shows that endotracheal lidocaine
in about fifty percent of the cases, it is present during extubation due to administered through a dispersion steam reduced the incidence of
laryngeal reflex inhibition caused by the residual effects of general coughing and hemodynamic changes when compared to a similar dose
anesthesia. Although, awake extubation constitutes a safe procedure, it of IV lidocaine. This technique makes extubation more comfortable,
is uncomfortable for the patient because of the hemodynamic changes, less traumatic, and allows patients emerging from anesthesia to tolerate
coughing and push that may occur. We have designed an dispersion an endotracheal tube while also affording airway protection with intact
steam, an instrument to administrate lidocaine directly into the trachea supraglotic reflexes.
allowing a better tolerance to the endotracheal tube in the awakening REFERENCES:
phase of the anesthesia. The purpose of this study was to compare the 1. Anesth Analg 79(4):792-5,1994.
tolerance to endotracheal tube and the hemodynamic changes during
extubation after topical lidocaine administered through an dispersion
steam versus intravenous lidocaine(1).
METHOD: Following IRB approval and informed consent, 60 ASA I-
II adult patients S undergoing general inhalated anesthesia were
enrolled in this randomized, prospective, single-blinded study. Study
subjects were equally divided (n=30 each) into dispersion steam (DS
group) and IV lidocaine group (L group). Anesthesia induction and
maintenance were standardized. At the end of surgery and when the
end-tidal isoflurane concentration was 0.2% the DS group received
Lidocaine 1.5 mg/kg through a dispersion steam and the L group
received lidocaine 1.5 mg/kg IV. In all cases the extubation was carried
out with the patient awake responding to commands. Incidence of
coughing, patient recall and discomfort, heart rate, blood pressure, and
extubation time were recorded and analyzed by unpaired t-test, one-way
ANOVA or Chi square as appropriate. P<0.05 was considered
statistically significant.
The dispersion steam has a longitude of 32 centimeters, with an internal
diameter of 0.5 millimeters, external of 1.2 millimeters; at its end, it has
12 lateral holes and one in the tip to distribute homogeneously the local
S-163
DIFFERENT CONTINUOUS TOTAL INTRAVENOUS pratictical method. This report describes preliminary experience with
ANESTHESIA TECHNIQUE IS RECOMMENDED FOR WAKE- this technique.
UP TEST (A PRELIMINARY STUDY) REFERENCES:
1. Onaka M, Yamamoto H, Akatsuka M, Mori H. Continuous total
AUTHORS: A. Yilmazlar1, R. Kuruefe2, B. Ozcan2, U. Aydinli2, C. intravenous anesthesia is recommended for wake-up test. Masui
Ozturk2 48:897,1999
AFFILIATION: 1Uludag University, Bursa, Turkey, 2Uludag 2. Rodola F,D’Avolio S, Chierichini A et al. Wake-up test during major
University Medical School, Bursa, Turkey. spinal surgery under remifentanil balanced anaesthesia.Eur Rev Med
Pharmacol Sci 4: 67-70,2000
INTRODUCTION: Total intravenous anesthesia (TIVA) is one of the
most recommended anesthetic method for wake-up test (1,2).
MATERIAL AND METHOD: Thirty eight ( 8 male, 30 female, ASA
class I-II patients whose ages ranged 9y-31y, weight ranged 20kg- 85
kg) scolyosis surgery cases were received TIVA consist of midazolam,
mivacurium, alfentanil infusions. Infusion rates were decreased in each
surgery phase until wake-up (Table I)
PHASE 3
PHASE 1 PHASE 4 PHASE 5
INFUSION (ROTE
(EXPOSURE) (CORRECTION) (WAKE-UP)
IMPLANTATION)
Midazolam
0.225 0.15 0.075 0
mg/kg/hour
Mivacurium
0.375 0.25 0.125 0
mg/kg/hour
Alfentanil
0.03 0.03 0.03 0.03
mg/kg/hour
At the surgeon’s request midazolam and mivacurium infusions were
discontinued, flumazenil was given, patients were asked to move hands
and feet.
RESULTS: The median intraoperative wake-up times were 5.7
minutes. The protocol the authors set up allowed a very rapid
intraoperative neurological examination without pain and no
complication releated to the test was observed
CONCLUSION: Authors concluded that decreasing infusion rates of
total intravenous anesthetics until wake-up test seems to be a safe and
2003; 96; S-1–S-293
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MIDAZOLAM-FLUMAZENIL VERSUS PROPOFOL
ANESTHESIA IN THE SCOLIOSIS SURGERY
AUTHORS: A. Yilmazlar1, R. Kuruefe2, U. Aydinli2, C. Ozturk2, O.
Kutlay2
AFFILIATION: 1Uludag University, Bursa, Turkey, 2Uludag
University Medical School, Bursa, Turkey.
INTRODUCTION: Wake-up test is still useful test in the scoliosis
surgery to ensure that spinal function remains intact.
METHODS: Intra-operative wake-up tests were performed in 60
patients randomized to either midazolam (M) or propofol (P) infusions
for scoliosis surgery. Other anaesthetic medication was similar in both
groups. At the surgeon's request, N2O was turned off and midazolam or
propofol infusions were discontinued. In the M group, flumazenil was
given in refracted doses. Patients were asked to move hands and feet.
RESULTS: The quality of intraoperative arousals was significantly
better in the M group. Wake-up tests were smooth and also no patient
recall of the test and no pain. All the patient in the P group had explicit
recall of the test, but no pain. Two of these patients woke up violently.
There were no neurological sequelae and no false negative results in
both group.But, on the other hand the median intraoperative wake-up
times were 5.7 min in the M group and 3.5 min in the P group(p<0.05).
CONCLUSIONS: Wake-up tests can be safer and better with
midazolam-flumazenil anesthesia compared with propofol anesthesia.
REFERENCES:
1)Koscielniak-Nielsen ZJ, Stens-Pedersen HL, Hesselbjerg L.
Midazolam-flumazenil versus propofol anaesthesia for scoliosis surgery
with wake-up tests. Acta Anaesthesiol Scand 1998; 42(1):111-6
Neuroanesthesia
Neuroanesthesia
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S-165
DUAL EFFECTS OF DEXMEDETOMIDINE ON REACTIVE % of control (n.s. vs high dose), and increased to 160±19 % of control
HYPEREMIA AND INFARCT SIZE FOLLOWING FOCAL that was significantly greater compared to the rats with high dose.
CEREBRAL ISCHEMIA IN RATS Cerebral infarction was confirmed in six out of eight rats infused with
high dose of dexmedetomidine, while infarction was seen one out of
AUTHORS: H. Kimotsuki, H. Okamoto, S. Hoka eight rats with low dose of dexmedetomidine (significantly lower
AFFILIATION: Kitasato University, Sagamihara, Japan. incidence). The calculated infarct size in the high dose rats was 12.5
folds of that in the low dose (p<0.05).
BACKGROUND: It has been reported that a selective alpha 2 agonist, DISCUSSION: High dose of dexmedetomidine suppressed reactive
dexmedetomidine, causes cerebral vasoconstriction and decreases hyperemia and increased infarct size following focal cerebral ischemia,
cerebral blood flow in vivo. Although neuroprotective effects of while low dose of dexmedetomidine did not significantly alter them.
dexmedetomidine have been shown in some reports, little is known This anti-neuroprotective effects of high dose of dexmedetomidine may
whether this direct cerebrovasoconstrictive action of dexmedetomidine be due to the direct cerebral vasoconstrictive effects. Therefore, it is
deteriorates ischemic brain damage. Therefore, in this study, we suggested that high dose of dexmedetomidine should be avoided during
examined the effects of dexmedetomidine on reactive cerebral cerebral ischemia. In contrast, low dose of dexmedetomidine may
hyperemia and cerebral infarct size following focal cerebral ischemia. preserve reactive hyperemia and lessen infarct size, and thus it may be
METHODS: Sixteen male Sprague-Dawley rats were used under an neuroprotective during cerebral ischemia.
approval of Institutional Animal Care and Use Committee. After
intraperitoneal injection of pentobarbital sodium (50mg/kg), rats were
mechanically ventilated with air. We continuously measured left
parietal cerebral blood flow (CBF) through the parietal cortex using
laser Doppler flowmetry and mean arterial blood pressure (MAP) . At
the end of preparations, continuous intravenous infusion of either high
or low doses of dexmedetomidine (1 or 0.1µg/kg/min, n=8 each) was
started. Focal cerebral ischemia was induced by the left middle cerebral
artery occulusion for an hour using a thread with its tip coated by vinyl
silicone. Reperfusion was made by withdrawing the thread. At the end,
animals were sacrificed and the brain was dissected and its slices was
soaked with 2,3,5 –triphenyl-tetrazolium-hydrochloride (TTC) to
measure the cerebral infarct area. Results were expressed mean±SD.
For statistics, ANOVA with Student-Newman-Keuls or X square
significance test were used. A p<0.05 was considered significant.
RESULTS:At control, CBF was not significantly different between
both groups of rats, whereas MAP was greater in rats with high dose of
dexmedetomidine. In rats receiving the high dose of dexmedetomide
(1µg/kg/min), CBF decreased to 27±9 % of control during ischemia,
and increased to 139±29 % of control after reperfusion. In rats with the
low dose of dexmedetomidine ( 0.1µg/kg/min), CBF decreased to 33±6
S-166
DEXMEDETOMIDINE SEDATION FOR AWAKE CAROTID and 1.2+2.0 respectively. Mean OAA/S was 4.2+0.5. PaCO2 levels were
ENDARTERECTOMY: RATIONALE AND SAFETY unchanged from baseline throughout the procedure. 4 patients required
placement of a shunt due to mental status changes after cross clamping
AUTHORS: A. Bekker, J. Basile, M. Gold, T. Riles and 13 others required phenylephrine to maintain adequate blood
AFFILIATION: New York University Medical Center, New York, NY. pressure. Two patients required conversion to a general anesthesia. The
plasma epinephrine concentrations did not change significantly during
INTRODUCTION: Regional anesthesia for carotid endarterectomy the procedure. Plasma norepinephrine concentration decreased by 31%
(CAE) allows for the evaluation of cognitive function intraoperatively (p=0.04) after 46+19 minutes of dexmedetomidine infusion and by 46%
and is associated with a lower requirement for shunting. A cervical at the end of the procedure (p=0.01).
plexus blockade provides excellent analgesia for most patients DISCUSSION: Dex sedation provides a stable and predictable
undergoing CAE, but usually requires sedation. A combination of anesthetic profile without hampering a mental status evaluation or
midazolam and fentanyl generally provides an adequate balance of causing respiratory depression. 52% of patients, however, were treated
sedation, cooperation and hemodynamic stability. Over and under with phenylephrine to maintain systemic blood pressure within 20% of
sedation as well as an unacceptable level of hemodynamic and the baseline. The reduced level of norepinephrine may reduce the rate of
respiratory variability can, however, be a problem. Dexmedetomidine cardiovascular complications. Thus, Dex may be an attractive
(Dex) is a highly specific alpha-2 adrenoreceptor agonist with sedative, alternative to standard sedation techniques during awake CEA.
analgesic and anesthetic-sparing effects. It is distinct from other REFERENCES
sedative agents in that it does not depress respiratory function, and 1. Anesth Analg 2001; 92:1251-3
patients can be easily aroused (1). The objective of this study was to
prospectively evaluate the safety an efficacy of Dex during regional
anesthesia for CAE.
METHODS: 25 patients underwent CEA under deep and superficial
cervical plexus blockade using 1.5% mepivacaine + epinephrine
1:200,000. An initial loading dose of 0.5 g/Kg/min of Dex was given
over 15 min followed by a continuous infusion of 0.1 to 0.4 g/Kg/hr.
The infusion rate was titrated to maintain a sedation level of 4 as
measured by the Observer’s Assessment of Alertness/Sedation Scale
(OAA/S). The degree of pain, sedation and anxiety were self-assessed
by the patients using a 10 point visual analogue scale (VAS). A motor
function of the hand on the side contralateral to surgery was assessed to
evaluate the adequacy of cerebral perfusion at the time of the carotid
artery cross-clamping. Plasma levels of epinephrine and norepinephrine
were measured preoperatively, 15 minutes after skin incision, and at the
end of the procedure.
RESULTS: All patients reported acceptable analgesia from the block
overall. Although readily aroused, patients reported a mean VAS
sedation score of 3.1+2.6. Mean VAS for pain and anxiety were 1.8+1.9
2003; 96; S-1–S-293 S-168
S-167
THE NEUROPROTECTIVE EFFECT OF XENON Neurological Score Infarct Volume (mm3 )
ADMINISTRATION DURING TRANSIENT MIDDLE
General Focal
CEREBRAL ARTERY OCCLUSION IN MICE Group Total Cortex Subcortex
deficits deficits
AUTHORS: H. M. Homi1, N. Yokoo1, D. Ma2, D. S. Warner1, M. 70%Xe 9 ± 2† 12 ± 5† 45.2 ± 17.4* 24.1 ± 9.9* 21.0 ± 8.2†
Maze2, H. P. Grocott1 70%N2O 10 ± 2 16 ± 6 59.4 ± 11.5 35.5 ± 8.6 23.9 ± 4.8
AFFILIATION: 1Duke University Medical Center, Durham, NC,
2
Imperial College of Science, London, United Kingdom. 35%Xe/
9±2 14 ± 5 49.8 ± 14.3* 26.6 ± 8.9* 23.2 ± 6.9
35%N2O
INTRODUCTION: Xenon, a noble gas possessing anesthetic
properties, is known to be an N-methyl-D-aspartate (NMDA) receptor Values are mean ± SD, n=21 in each group. †P<0.05 and *P < 0.01
antagonist (1). Neuroprotection has been demonstrated in several in compared to the 70% N2O + 30% O2 group.
vitro and in vivo models of brain injury but has not been studied in the DISCUSSION: In this model of transient focal cerebral ischemia,
setting of cerebral ischemia (2). The purpose of this investigation was to xenon improved both functional and histologic outcome. These findings
evaluate the neuroprotective effect of xenon in a mouse model of are consistent with its action as an NMDA receptor antagonist (1) and
transient focal cerebral ischemia. with previous studies demonstrating reduction of NMDA-induced
METHODS: Fasted mice (male, 8 week old C57BL/6) were neuronal injury in vitro and NMA-induced hypothalamic arcuate
anesthetized with isoflurane, intubated, ventilated and surgically nucleus injury in vivo (2).
prepared for right middle cerebral artery occlusion (MCAO). Mean REFERENCES:
arterial pressure and pericranial temperature (servo-controlled to 37°C) 1. Nature 396:324;1998. 2. Anesthesiology 96:1485-91;2002.
were continuously monitored. Following surgical preparation, the
isoflurane was discontinued, all animals received fentanyl (50 µg/kg i.v.
bolus; 50 µg/kg/hour i.v. infusion), and were randomized to one of three
anesthetic groups (n=21 in each group): 70% Xe + 30% O2; 70% N2O +
30% O2 and 35% Xe + 35% N2O + 30% O2. Sixty minutes of MCAO
was then performed followed by 24 hours of reperfusion. The animals
then underwent neurological evaluation by a blinded observer using two
scoring systems following which they were euthanized with the brain
removed for infarct volume analysis. Parametric data were compared
amongst groups using ANOVA (followed by the Scheffe test) with non-
parametric data analyzed using Kruskal-Wallis and Mann-Whitney U
tests. A P<0.05 was considered significant.
RESULTS: The neurological scores and brain infarct volumes are
summarized in the table below. The 70% Xe + 30% O2 group had both
improved functional as well as histologic outcome compared to the 70%
N2O + 30% O2 group. The 35% Xe + 35% N2O + 30% O2 group had an
intermediate outcome.
S-168
THE EFFECTS OF BETA-BLOCKERS ON CEREBRAL CONCLUSION: It is concluded that both labetolol and esmolol are
ARTERY BLOOD FLOW VELOCITY DURING effective in preventing hypertension in patients undergoing ECT, but
ELECTROCONVULSIVE THERAPY that labetolol, and not esmolol, may attenuate the initial increase in
CBV. Further studies have to elucidate if this finding is important as to
AUTHORS: A. P. Chandel, P. J. Van der Starre, H. B. Solvason, J. G. the duration and quality of the seizures2.
Brock-Utne REFERENCES:
AFFILIATION: Stanford University, Stanford, CA. 1. Ding Z, White PF. Anesth Analg 2002;94:1351-64. 2. Kovac AL,
Goto H, Pardo MP, Arakawa K. Can J Anaesth 1991;38:155-8
INTRODUCTION: Electroconvulsive therapy (ECT) has an important
role in the treatment of patients with severe depression or typical pattern in three different patients
schizophrenia. ECT results in an acute cardiovascular response, No med- No med- No med- Labe- Labe- Labe-
characterized by tachycardia, hypertension, and increase in cerebral ication ication ication tolol tolol tolol
EsmololEsmololEsmolol
artery blood flow velocity (CBV)1. In patients with a history of
HR BP CBV HR BP CBV HR BP CBV
hypertension mostly beta-blockers are administered pre- or post-ECT to
prevent a further increase in blood pressure. In this study we evaluated Baseline 95 129/76 50 67 150/74 44 70 135/85 73
the effects of beta-blockers on changes in CBV using Transcranial 0.5 min 110 174/90 102 85 160/95 44 68 151/85 150
Doppler (TCD) measurements both in hypertensive and non- 5 min 130 140/86 90 74 160/85 60 66 160/95 89
hypertensive patients.
10 min 120 140/75 50 74 160/85 73 69 160/85 70
METHODS: The study was approved by the IRB, and written
informed consent was obtained. Eleven patients underwent 15 ECT’s 30 min 107 125/85 50 76 155/80 43 76 120/68 68
under general anesthesia, consisting of methohexital 0.5-1 mg/kg and
succinylcholine (1 mg/kg). In case of pre-ECT hypertension (MAP >
100 mmHg) esmolol or labetolol were administered intravenously.
CBV, heart rate (HR) and arterial blood pressure (BP) were measured
just before induction of anesthesia, and at 0.5, 5, 10 and 30 min post-
ECT.
RESULTS: CBV increased significantly (90-100%) at 0.5, 5 and 10
min after ECT in patients not receiving beta-blockers pre-ECT. HR
increased approximately 20 b/min at the same moments, but BP
increased only after 10 min. Patients receiving esmolol pre-ECT
followed the same pattern except for HR, which did not change. In
patients receiving labetolol pre-ECT, CBV did not significantly change
at 0.5 min, but at 5 and 10 min increased significantly, although BP did
not change (table 1).
After 30 min all values had returned to pre-ECT baseline levels in all
patients.
S-170 2003; 96; S-1–S-293
S-169
ASSOCIATION BETWEEN PLASMA CONCENTRATION OF control group (P=0.02). The mean value obtained in the poor outcome
NITRIC OXIDE PRODUCT (NITRATE & NITRITE) AND S100B group and good outcome group was 12.56 mol/l and 13.7 mol/l
PROTEIN AFTER SURGERY OF CEREBRAL ANEURSYM respectively in the first 48 hrs postoperatively (P=0.4).
CLIPPING AND PATIENT OUTCOME DISCUSSION: These findings suggest that S100 represents a better
marker of cerebral injury and outcome after cerebral aneurysm clipping
AUTHORS: K. Ghori1, R. Elashad1, D. C. Harmon1, F. Walsh2, M. G. than nitric oxide product concentrations.
O'Sullivan3, G. D. Shorten1 REFERENCES:
AFFILIATION: 1Cork University Hospital, Cork, Ireland, 2Cork 1. Haimoto H, Hosoda S. Lab Invest 1987;57:489-98.
University Hospital Cork, Cork, Ireland, 3Depatment of Neurosurgery, 2. Ingebrigtsen T. J Neurosurg 1996;85:945-8.
3. Büttner T. Stroke 1997;28:1961-5
Cork, Ireland.
INTRODUCTION: Despite the recent advances in brain imaging
techniques, it is still difficult to quantify the extent of primary and
ongoing secondary brain injury. The objective of this study was to
examine the usefulness of plasma S100 and nitric oxide products
concentrations (nitrate plus nitrite) (NOx) as markers of brain injury
following clipping of cerebral aneurysm in patients with spontaneous
subarachnoid hemorrhage (SAH).
METHODS: 15 patients with SAH and 10 control subjects (age
matched healthy volunteers) were included in the study. Blood samples
were obtained for estimation of plasma S100 and NOx at 10 minutes
after clipping of cerebral aneurysm, 2, 6 and 12 hrs postoperatively and
thereafter daily for 6 days. Outcome was assessed by using the Glasgow
Outcome Scale.
RESULTS: The mean pre-operative plasma concentration of S100 in
patients with SAH was increased (0.24g/l) compared to control group
(0.18 g/l)(P=0.03). After clipping of aneurysm plasma S100
concentration increased in 11 (84%) patients at two hours (mean 0.34 g/
l, median 0.28 g/l)(P=0.01) and in 12 (92%) patients at 12 hours (mean
0.31 g/l, median 0.02 g/l)(P=0.04) when compared to control group.
The mean S100 concentration obtained in the poor outcome group
(grade IV-V) was 0.45 g/l compared to 0.36 g/l (P=0.04) in the good
outcome group (grade I-III) in the first 48 hrs postoperatively. The
temporal profile of plasma NOx after clipping was a decreased plasma
concentration at 12 hrs and thereafter an increased plasma concentration
compared to control group. NOx concentration at 12 hrs postoperatively
in patients with SAH was 9.61 mol/l compared to 12.37 mol/l in the
S-170
DIFFERENTIAL EFFECTS OF BUPIVACAINE ON compromised. Disruption of mitochondrial membrane integrity is
MITOCHONDRIAL RESPIRATION IN BRAIN AND HEART possibly one of mechanism of bupivacaine induced neurotoxicity.
AUTHORS: C. Paisansathan1, G. Weinberg2, J. Palmer2, W. Hoffman2 Effect of bupivacaine on brain and heart mitochondria
AFFILIATION: 1Univ of Illinois at Chicago, Chicago, IL, 2Univ of Brain Heart
Illinois at Chicago, Chicago, IL.
State III State IV State III State IV
Bupivacain
INTRODUCTION: Bupivacaine is known to be both cardiotoxic and respiration respiration respiration respiration
e
neurotoxic since clinical overdose can result in cardiac arrest or seizure (ng atoms (ng atoms RCR (ng atoms (ng atoms RCR
activity. Bupivacaine is also an uncoupler of oxidative phosphorylation. concentrati
O2/min/ O2/min/ O2/min/ O2/min/
Mitochondrial respiratory ratio (RCR) is a measure of coupling, which on (mM)
mg) mg) mg) mg)
reflects inner membrane integrity. The ratio describes the difference
between mitochondria during ADP-supported oxygen respiration (state 0 226 19.7 7.8 202 18.1 11.2
III) and resting state respiration (state IV). The purpose of this study 0.5 187 29.6 6.3 191 20.3 9.5
was to compare brain and heart mitochondria in state III and state IV 1.0 165 42.3 3.9 191 20.2 8.0
and to calculate RCR during bupivacaine treatment.
METHODS: These studies received animal care committee approval. 2.0 160 57.8 2.8 180 35.6 5.1
Rats were decapitated, hearts and brains were harvested, tissue was
homogenized and mitochondria were isolated by differential
centrifugation. Oxygen concentration was measured in the
mitochondrial suspension using a Clark oxygen electrode.
Mitochondrial respiration was measured using pyruvate/malate as
substrates. States III and IV were initiated using low concentrations of
ADP. Bupivacaine concentrations were 0.5, 1.0 and 2 mM.
RESULTS: There was a decrease in state III respiration with increasing
concentration of bupivacaine in brain but not heart mitochondria (table
1). State IV respiratory rates increased with increasing bupivacaine
concentration, and this effect was greater in brain than heart
mitochondria. RCR decreased with increasing concentrations of
bupivacaine, and this effect was more pronounced in brain compared to
heart mitochondria.
DISCUSSION: These results show that bupivacaine suppresses
pyruvate-supported state III respiration in brain but not heart
mitochondria. Bupivacaine may affect metabolite translocation in brain
mitochondria by increasing inner membrane leakiness. State IV
respiration was increased and RCR was decreased by bupivacaine more
in brain than in heart, again indicating that membrane integrity was
2003; 96; S-1–S-293 S-172
S-171
EFFECTS OF INTRACELLULAR ACIDOSIS ON THE STEADY Table 1. kf and F for CPK before and during acidosis (25degC)
STATE RATES OF CREATINE KINASE IN RAT BRAIN
Control Acidosis Recovery
SLICES
pHi 7.17 6.91 7.17
1 2 1 1
AUTHORS: T. Kitano , N. Nisimaru , S. Kawabe , T. Nakamura , H. kf 0.12 0.06 0.14
Iwasaka1, T. Noguchi1
F (micromol/g wet/s) 0.76 0.23 0.89
AFFILIATION: 1Dept. of Anesthesiology, Oita Medical University,
Oita, Japan, 2Dept. of Physiology, Oita Medical University, Oita, Japan. The forward direction of the CPK reaction is the direction of PCr hydrolysis. The
flux calculations assume as in vivo [ PCr] of 6.36 µmol/g wet wt.
INTRODUCTION: Intracellular acidosis is one of the cytotoxic
mechanisms during ischemic brain injury. We showed in previously that DISCUSSION: It is reported that the optimal pH in the forward CPK
pre-conditioning with intracellular acidosis could induce resistance to reaction is 5-6 and in backward reaction 8-9. From the optimal pH data
the fall in high-energy phosphate (creatinephosphate, PCr) during in CPK, it might be anticipated that forward reaction was accelerated by
subsequent intracellular acidosis in rat brain slices1. In this study, we intracellular acidosis. However the rate in forward reaction was
investigate the exchange flux in creatine kinase (CPK) reaction before decelerated at pHi 6.91. Decreases in PCr and in the rate of backward
and during intracellular acidosis induced by hypercapnia using the reaction might be the major cause of the suppressed forward CPK rate.
method of phosphorus nuclear magnetic resonance (31P NMR) Pre-conditioning with intracellular acidosis might also modify the CPK
rate constant
saturation transfer.
METHODS: Brain slices were obtained from male Wister rats (6-10 REFERENCES:
week, N=6). The slices were incubated in artificial cerebrospinal fluid 1) Kitano T, Nakamura T, Kawabe S et al., Fall in high energy
phosphate levels during intracellular acidosis is inhibited by pre-
(ACSF), bubbled with 5% CO2, 60% O2 plus 35% N2 at 25°C for 1h.
31
conditioning in rat brain slices. Anesth Analg 2002; 94: 111S
P-NMR spectra were obtained using a Bruker AMX300wb 2) Shoubridge EA, Briggs RW, Radda GK, 31P NMR Saturation transfer
spectrometer. After the steady levels of PCr and inorganic phosphate measurements of the steady state rates of creatine kinase and ATP
(Pi) were reached, intracellular acidosis was induced by changing gas synthetase in the rat brain. FEBS letters 1982; 140: 288-292
mixture from 5% to 20-40% CO2 and then returned to 5% CO2.
Intracellular pH (pHi) was calculated from the chemical shift of Pi. The
method of 31P-NMR saturation transfer was according to the procedures
of Shourbridge et al.(1982)2 with modification
RESULTS: pHi decreased from 7.4 to 6.4 following increase of CO2 in
bubbling gas mixture from 5 to 40%. The level of PCr decreased rapidly
and that of Pi increased at pHi less than 6.9. Pseudo-first order rate
constant in forward reaction (kf) and flux (F) for CPK decreased during
acidosis induced by hypercapnia as shown in Table 1.
S-172
CARDIOVASCULAR CHANGES DURING ENDOSCOPIC REFERENCES:
THIRD VENTRICULOSTOMY IN CHILDREN 1/ Anesth. Analg. 2000; 91; 1142-4
2/ Clinical Anaesthesiology 2002; 16: 81-93
AUTHORS: J. Van Aken, T. Verplancke, L. De Baerdemaeker, M. 3/ Intracranial pressure III. Springer Verlag Berlin Heidelberg Ed 1976
Struys, J. Caemaert, E. Mortier p 270.
AFFILIATION: Ghent University Hospital, Gent, Belgium. 4/ Neurosurgery 1994; 35: 525-8.
INTRODUCTION: Little attention has been paid to the cardiovascular Cushing-group (n=3)
changes during anesthesia and surgery for endoscopic third
ventriculostomy (ETV). A negative correlation between bradycardia variable median minimum maximum
(B) and third ventricular pressure during ETV was reported (1). Blood age 7 years 4 months 10 years
pressure (BP) or tachycardia (T) were not discussed. More recently was weight (kg) 30 6.3 30
stated that invasive blood pressure measurement is unnecessary during
endoscopic surgery in pediatrics (2). Because this contrasts with our heart rate/min (highest) 140 130 140
experience, we studied retrospectively the incidence of B,T, systemic heart rate/min (lowest) 70 55 105
hypertension and the occurrence of an increased intracranial pressure systolic BP (highest) 200 120 210
(ICP).
METHODS: After IRB approval, the anesthesia records of 37 patients systolic BP (lowest) 85 75 100
who underwent an ETV during the last 12 years were examined. diastolic BP 50 40 60
Anesthesia was induced and maintained with propofol, cisatracurium
and remifentanil or alfentanil. A radial or femoral artery was cannulated
with a 22 or 24G catheter to monitor beat to beat the BP. The heart rate
was recorded continuously via the ECG. In children, we considered B or
T to be present if the heart rate decreased below or increased above the
range according to the age of the child. Hypertension was defined as a
BP above the 95th percentile for age.
RESULTS: In 26 patients the procedure was uneventful. An isolated T
or B was observed in 6 and 4 patients respectively. In 3 patients the T
coincided with a systemic hypertension (table). In these patients an
increase in ICP was likely present, due to a kinking of the irrigation
fluid outflow tubule or a forceful inflow of the irrigation fluid to clear
an obtunded view by blood.
DISCUSSION: Since B as well as T can occur during ETV, it is of
outmost importance to monitor the BP beat tot beat invasively. In this
way, the surgeons can be warned in the early fase of a Cushing
response, when T and systemic hypertension are present (3). Waiting
for a persistent B could result in a fatal asystole (4).
S-174 2003; 96; S-1–S-293
S-173
SONOCLOT ANALYSIS IN NEUROSURGICAL PATIENTS monitor of accelerated peri/postoperative fibrin formation in this
population, and supports prior findings of hypercoagulability in this
AUTHORS: E. G. Pivalizza, M. P. Wenzel patient group (4). Although changes in SonACT did not reach statistical
AFFILIATION: University of Texas - Houston, Houston, TX. significance, the trend in decreasing values (+ 40% from baseline to
postop) may be of greater clinical significance. These findings suggest
INTRODUCTION: The Sonoclot analyzer, which has been used to that investigation be continued to elucidate the role of the Sonoclot in
monitor perioperative coagulation (1,2,3), has not been investigated in neurosurgical patients, and in particular, for extension of monitoring to
neurosurgical patients. As these patients may be at risk for either hyper patients with pre-existing or developing coagulation abnormalities and
or hypocoagulable chnages (4,5), we investigated changes in Sonoclot those with traumatic brain injuries.
parameters in patients undergoing craniotomy. REFERENCES.
METHODS: After institutional approval and informed consent, 1. Br J Anaesth 1995:75;771-6.
patients undergoing elective craniotomy were enrolled. Patients 2. Mayo Clin Proc 1997:72;241-9.
receiving any medication affecting coagulation or with abnormal 3. Anesth Analg 1998:87;1228-33.
baseline coagulation parameters were excluded. Blood was drawn from 4. Surg Neurol 1997:47;35-8.
a central venous line for Sonoclot analysis (Sienco Inc., Broomfield, 5. Neurosurg 1992:30;160-5.
CO) after anesthetic induction, at 1 and 3 hours, at the end of surgery
and after 24 hours. Parameters measured included: SonACT (Sonoclot Sonoclot parameters (n = 25)
activated clotting time [sec]-representing the liquid phase of
coagulation up to initial fibrin formation); Clot rate (units/min Time to peak
SonACT (sec) Clot rate (U/ Peak amplitude
[Sonoclot scale of signature anplitude/viscosity] - the slope of the (p =0.08) min) (p = 0.4) (U) (p = 0.5)
amplitude
signature during fibrinogen to fibrin conversion); Peak amplitude (units, (min) (p = 0.2)
signifying completion of fibrin formation and initial platelet After induction 141.5 + 44.2 31.6 + 15.5 87.6 + 19.9 15.7 + 6.3
interaction); and Time to peak amplitude (min, dependent on fibrin and
platelet function). Patient demographics, hematology and coagulation After 1 hour 138.1 + 34.3 28.9 + 15.0 82.7 + 19.9 12.3 + 4.5
results, estimated blood loss and blood product administration were After 3 hours 139.5 + 29.9 28.3 + 12.6 82.6 + 14.9 16.3 + 7.0
recorded. Sonoclot parameters were compared by ANOVA with
Bonferroni correction for multiple comparison (significance assumed End surgery 123.8 + 26.0 27.3 + 12.1 76.5 + 17.5 14.0 + 6.1
with p < 0.0125). 24 hours postop 107.9 + 37.5 37.1 + 13.5 83.9 + 29.1 13.3 + 3.8
RESULTS: 25 patients were enrolled (7 male, age 48.5 + 11.9 years),
undergoing aneurysm (14), AV malformation (3), tumor (2) or other
intracranial surgery. Coagulation parameters remained withing normal
limits. Sonoclot parameters (table) demonstrated a continual trend
towards a decreased end of surgery and postoperative SonACT although
this did not reach statistical significance.
DISCUSSION: Although the Sonoclot analyzer has been used in
surgical patients at risk for altered coagulation (1,3), there is no data for
neurosurgical patients. Our data in patients undergoing craniotomy with
normal baseline coagulation suggest that the SonACT may be a useful
S-174
EARLY MITOCHONDRIAL CHANGES IN RESPONSE TO independent of apoptosis.
ISCHEMIA-LIKE INJURY - EFFECTS OF BCL-XL REFERENCES:
(1) Papadopoulos et al. Europ J Neurosci, 10: 1252, 1998
AUTHORS: R. G. Giffard, Y. Ouyang
AFFILIATION: Stanford University, Stanford, CA. Funded in part by an IARS Frontiers Award and NIH-NS37520
INTRODUCTION: Bcl-xL is a member of the Bcl-2 family and blocks

apoptotic and necrotic cell death. We have previously shown that it is
effective in reducing glucose deprivation (GD) induced astrocyte death
(1). Despite investigations in many labs the mechanism of protection
remains unclear, but is likely to involve mitochondrial function.
METHODS: Primary mouse cortical astrocyte cultures were studied
using the potentiometric dye TMRE to follow the time course of
changes in mitochondrial membrane potential in live cells subjected to
glucose deprivation. In addition, oxygen consumption was used to
assess oxidative respiration as a measure of mitochondrial function.
ATP and ADP levels were also measured.
RESULTS: As early as 3 h after removal of glucose mitochondria
showed hyperpolarization and state III respiration decreased
significantly. This is a time point well before cytochrome c is released.
Damage to the electron transport chain is not responsible for this change
because uncoupled respiration (measured after adding CCCP) did not
change. At 5 h of GD when mitochondrial depolarization was observed,
state IV respiration increased significantly. Bcl-xL over-expression
prevented both the decrease in state III respiration and mitochondrial
hyperpolarization. The slight increase in state IV respiration in Bcl-xL
astrocytes was consistent with the slight gradual depolarization during 5
h of GD. The possibility that Bcl-xL facilitation of ATP/ADP exchange
could explain the differences in membrane potential was excluded by
measuring cytoplasmic and mitochondrial ATP/ADP ratios.
DISCUSSION: Bcl-xL protection is associated with maintaining
normal state III and slightly increased state IV respiration. Although
Bcl-xL is associated with regulation of apoptosis the effects on
mitochondrial function seen early in GD precede any evidence of
apoptosis, such as release of cytochrome c from mitochondria. This
work demonstrates Bcl-xL effects on mitochondrial function during
mild stress, suggesting direct effects on mitochondrial function
Obstetric Anesthesia
Obstetric Anesthesia
S-176 2003; 96; S-1–S-293
S-175
BISPECTRAL INDEX VALUES AT SEVOFLURANE between Group 1 and Group 2 at skin incision (64 vs 52*), uterine
CONCENTRATIONS OF 1% AND 1.5% IN LOWER SEGMENT incision (65 vs 39.5#), delivery of neonate (66 vs 42#) and 10 minutes
CESAREAN SECTION after delivery (63 vs 42.5#). There were no significant differences
between the 2 groups with regard to intra-operative hemodynamics,
AUTHORS: K. Chin, S. Yeo blood loss, neonatal Apgar scores, emergence times or recovery
AFFILIATION: KK Women's and Children's Hospital, Singapore, characteristics. None of the patients reported intra-operative recall.
Singapore. DISCUSSION: End-tidal sevoflurane 1.5% reliably maintained BIS at
levels <60 prior to delivery of the neonate in LSCS, whereas
INTRODUCTION: A bispectral index (BIS) of 60 appears to represent sevoflurane 1.0% did not. Prevention of awareness in LSCS may
the threshold below which consciousness is unlikely 1. Isoflurane 0.5% require an end-tidal sevoflurane concentration greater than 1.0% prior
in 50% nitrous oxide is commonly used in lower segment cesarean to administration of opioids.
section (LSCS) but does not reliably achieve BIS values <60 2. REFERENCES:
Inadequate hypnosis may therefore partly account for the increased risk 1. Anesthesia. 5th Ed, 2000, 29:1087-1113.
of awareness in LSCS, especially since opioids are avoided prior to 2. Anaesth Int Care, 2002, 30(1):36-40.
delivery of the neonate. Sevoflurane 1.0% has been shown to be 3. Anesth Analg , 1995, 81(1):90-95.
equivalent to isoflurane 0.5% when used in this setting 3. The aim of this
study was therefore 1) to determine the BIS values achieved with an
end-tidal sevoflurane concentration of 1.0%, and 2) to determine if a
higher end-tidal concentration of 1.5% would consistently produce BIS
values <60.
METHOD: Following institutional approval, 20 ASA 1-2 parturients
requesting general anesthesia for elective LSCS were randomized into 2
groups. Group 1 was maintained at an end-tidal sevoflurane
concentration of 1.0% throughout the operation, whilst Group 2 was
maintained at 1.5%. Sevoflurane was administered in 50% nitrous oxide
until delivery; thereafter nitrous oxide was increased to 66%.
Thiopental 4 mg/kg and succinylcholine 1.0-1.5 mg/kg were used for
induction. Morphine 0.1-0.15 mg/kg, and oxytocin 10 IU were given
following delivery of the neonate. BIS values during anesthesia were
recorded together with other indices of maternal and neonatal outcome.
Patients were interviewed post-operatively regarding intra-operative
recall. Results were analyzed using the Mann-Whitney U-test for BIS Figure 1. Intraoperative BIS values. Black bars = median, boxes = 25-
data, and Student‘s t test for other data. A p-value <0.05 was considered 75th percentiles, lines = 10-90th percentiles.
statistically significant* and <0.01 highly significant#.
RESULTS: Median BIS values in Group 2 were <60 at all times during
the operation. Median BIS values in Group 1 exceeded 60 prior to
delivery, except at intubation. BIS values were significantly different
S-176
PROPOFOL PROVIDES BETTER ANESTHESIA THAN later. Higher incidence of nausea was noted in group K(24.4%) than
KETAMINE/DIAZEPAM SEDATION FOR TRANSVAGINAL group P(9.4%) or group PN(2.0%) 2 hours later. Dizziness was two
OOCYTE RETRIEVAL WITHOUT ADVERSELY AFFECTING times higher in group K even when 2 hours had elapsed. About 20% of
REPRODUCTIVE OUTCOME the patients in each remembered a dream, only one dream in group K
was described unpleasant. Reproductive outcome study. The number of
AUTHORS: J. Uchida cycles in each group was; P(267), PN(812), K(144). The dose of
AFFILIATION: Center for Maternal Fetal and Neonatal Medicine, anesthetic agent was; P(propofol 298±86.2g), PN(propofol 294±92mg,
Saitama Medical Center, Kawagoe, Japan. N2O 66%), K(ketamine 51.0±11.7mg, diazepam 10mg). Reproductive
outcomes in group P, PN, K, respectively, were not statistically different
INTRODUCTION: Best anesthetic method for transvaginal oocyte with regard to retrieval success rate (98.8%, 99.3%, 98.6%),
retrieval for in vitro fertilization (IVF) is not established. Propofol is fertilization rate (90.6%, 94.7%, 96.4%), pregnancy rate (25.1%,
expected to provide adequate anesthesia with rapid recovery, but it may 26.6%, 30.3%). However, when ICSI (intracytoplasmic sperm
adversely affect reproductive outcome, because some in vitro animal injection) cases were excluded, fertilization rate of group P was
studies have suggested its interference with blastocyst formation. Thus significantly lower than group PN (90.3% vs. 95.2%, P<0.05).
we compared the quality of anesthesia of propofol with ketamine/ DISCUSSION: Propofol based general anesthesia for oocyte retrieval
diazepam sedation as well as their effects on reproductive outcome in provides adequate anesthesia with good recovery profile, compared
IVF. with the ketamine based sedation. However, analgesic supplementation
METHODS: Our institutional review board approved the following may be warranted. Reproductive outcome is not worse when propofol is
two studies. Anesthesia quality study. Patients undergoing oocyte used for anesthesia in oocyte retrieval.
retrieval in the year 2000 were divided into three groups depending on
the anesthetic agent according to the discretion of the anesthetist as
follows: propofol only (group P), propofol-nitrous oxide (group PN),
and ketamine/diazepam/atropine (group K). Incidence of intraoperative
recall, pain, nausea, dizziness and dream were prospectively collected
immediately after the procedure and two hours later at the time of
discharge. Reproductive outcome study. Records of 1223 cycles for IVF
from January 2000 to June 2002 were retrospectively reviewed in terms
of dose of anesthetic agents, retrieval success rate, fertility rate, and
pregnancy rate. The results were compared among the groups P, PN, K
as described in anesthesia quality study, using Chi-square test.
RESULTS: Anesthesia quality study. The number of patients in each
group were; P:87, PN:105, K:57. The dose of propofol between P and
PN were not different (273mg vs.278mg, respectively). None of the
patients in group P and PN had intraoperative recall, but 21% of group
K had recall. Incidence of pain was significantly lower in group
K(23.0%) as opposed to group P(51.7%) or group PN(57.7%)
immediately after the procedure, but the difference resolved 2 hours
2003; 96; S-1–S-293 S-178
S-177
PERINATAL MANAGEMENT OF ANTENATALLY Cesarean section. Maternally administered drugs include fentanyl,
DIAGNOSED CONGENITAL DIAPHRAGMATIC HERNIA: diazepam, propofol, sevoflurane. Direct umbilical vein drug
SURVEY OF PRACTICE IN JAPAN administration, as originally proposed by Tamura, was practiced in only
3 centers in Japan, and they administer pancuronium and morphine.
AUTHORS: K. Terui With regard to the neonatal outcome, half of the respondents had the
AFFILIATION: Center for Maternal Fetal and Neonatal Medicine, opinion that this practice did not improve neonatal outcome.
Saitama Medical Center, Kawagoe, Japan. Availability of advanced neonatal management modalities was quite
high except for ECMO; HFO: 82.7%, NO: 68.9%, ECMO: 37.9%.
INTRODUCTION: Neonates with congenital diaphragmatic DISCUSSION: This survey revealed that the concept of deliberately
hernia(CDH) remains to have high mortality rate despite antenatal delivering depressed neonate by Cesarean section is widely accepted
diagnosis followed by elective Cesarean delivery. Recently, Japanese when CDH is diagnosed antenatally. However, still half of the
neonatologists advocated the deliberate delivery of a depressed, apneic respondents doubt its benefit. This may be due to the variable drug
neonate by Cesarean section in order to prevent gastric distension and regimen with inadequate neonatal effect. Further refinement of the
PPHN. The preliminary report seems promising1). However, the safe protocol and the follow up of outcome seems necessary before adopting
and effective drug regimen or route of delivery (umbilical vein injection this new idea of perinatal management for CDH.
and/or maternal administration) for this purpose has not been REFERENCE:
established. There is also a concern for the maternal safety when Tamura M: Jpn J Pediatric Surg 1994;26:1055-61.
general anesthesia is advocated for this practice. Thus we conducted the Hoshino Y; Uezono S; Taniguchi Y, et al: Anesthesiology 2001;
nationwide survey of perinatal management of CDH with emphasis on 95:A1283
the anesthetic management for Cesarean section.
METHODS: After institutional review board approval, telephone
survey was conducted to the chief anesthesiologist of 29 registered
centers for maternal fetal medicine in Japan. Questions include mode of
delivery, protocol of fetal anesthesia for deliberately depressing the
neonate, type of anesthesia for Cesarean section and anesthetic agent.
Opinion was also asked whether or not fetal anesthesia improved
neonatal outcome. Neonatal management questions include availability
of HFO, ECMO, NO.
RESULTS: All the centers responded to the survey. Chief
anesthesiologist responded in all institutions except two, in which
obstetrician or pediatric surgeon was considered more suitable for the
survey. Four institutions lacked pediatric surgery service, thus the
remaining 25 institutions were included in the analysis. 84% of the
centers preferred elective Cesarean delivery. While only 53% had the
protocol of fetal anesthesia at the time of survey, 72% of the
respondents aimed for delivering the depressed neonate, the so-called
"sleeping baby". For this purpose, 77% chose general anesthesia for
S-178
ENOXAPARIN THERAPY DURING PREGNANCY AND heparin therapy so that the patients could receive regional anesthesia
MANAGEMENT OF LABOR ANALGESIA during labor and delivery (Table). Factor Xa levels are not measured
during EN therapy or when regional anesthesia is given. There were no
AUTHORS: H. Finegold1, C. Ohara2, S. Ramananathan3 bleeding complications nor were there any adverse maternal or fetal
AFFILIATION: 1Magee Womens' Hospital - Univeristy of Pittsburgh outcomes associated with the use of regional anesthesia in these patients
School of Medicine, Pittsburgh, PA, 2Magee Womens Hopsital- (Table).
University of PIttsburgh School of Medicine, Pitttsburgh, PA, 3Magee
Womens Hospital-University of PIttsburgh School Of Medicine, Enoxaparin Dosing Regimens and Fetal Outcomes
Pittsburgh, PA. Daily Dose of Enoxaparin (EN) Min =40
mg Average =61.5 Max =260
INTRODUCTION: Low molecular weight heparin therapy (LMWH), Weeks of Gestation EN Started
especially when given with concomitant aspirin therapy, has been (weeks) 13.4 +/- 8.08
associated with bleeding and specifically with epidural hematoma in Weeks of Gestation EN Stopped
those patients receiving epidural anesthesia. (weeks) 34.3 +/- 5.36
The purpose of this project was to determine the practice regimens and Hours Between Last EN dose
patient outcomes in parturients receiving LMWH and neuroaxial and Regional Anesthesia (hrs) 370.68 +/- 447.54 min =6.75 max=1782
anesthesia for labor analgesia at our institution.
Birthweight (g) 2992.82 +/-896.58
METHODS:With permission of the Institutional Review board, we
reviewed patients’ medical records over a period from 1998-2002. Apgar 1 min 7.91 +/- 0.39
Using ICD9 billing codes, we identified those parturients with diseases Apgar 5 min 8.89 +/- 0.47
associated with LMWH therapy, specifically Enoxaparin (EN). After
reviewing the information, we entered the data into a computer database
using Microsoft ACCESS™ software. Only those patients who received
LWMH therapy during their pregnancy were included with the
following data: date of birth, height, weight, maternal age, race, parity,
maternal diagnoses, concomitant aspirin usage, maximum daily dosage
of EN (mg), start and stop date of EN usage, hours between EN
stoppage and insertion of regional, type of regional anesthesia, mode of
delivery, apgar scores, birth weight.
RESULTS: We identified 50 patients who received LMWH during
their pregnancy. The most common primary diagnoses were: Factor V
Leiden deficiency (22/50), Systemic Lupus (4/50), Anti-Phospholipid
Syndrome (4/50), Thrombophillia (4/50).The remaining diagnoses
included embolic disease and coagulation disorders. Twenty- two out of
the 50 patients studied took Aspirin 81 mg daily throughout their
pregnancy in addition to the EN. The Obstetricians rountinely
discontinued the EN during the third trimester and began unfractionated
S-180 2003; 96; S-1–S-293
S-179
IS EPIDURAL-PCA ANALGESIA NECESSARY FOR A THIRD Pain Pain
DAY POST CESAREAN SECTION PAIN? Pain (rest
(ambulatio (cough at Sedation Nausea Pruritus
at 72 hrs)
AUTHORS: S. Cohen, H. Denenberg, R. Mohiuddin, N. Uzun, R. n at 72 hrs) 72 hrs)
Chhokra, A. Cohen Group 1 1.3±2.0 2.5±2.3 3.8±2.8 7(9%) 5(6%) 23(29%)
AFFILIATION: UMDNJ-Robert Wood Johnson Medical School, New Group II 2.7±2.6* 4.2±2.9* 5.2±3.0** 13(38%)* 5(15%) 1(3%)***
Brunswick, NJ. GII>I: *p<0.005, **p<0.03; ***GII<I, p<0.005.
INTRODUCTION: Our practice has been to provide epidural-PCA
ropivacaine 0.025% with fentanyl 3 mcg/ml & epinephrine 1 mcg/ml
for most of our post cesarean section (C/S) patients for 48 hrs. Very
often, patients requested to continue this treatment for another extra
day.
METHOD: We determined if epidural-PCA analgesia is necessary for
3rd day post C/S. 112 pts who received epidural-PCA for post C/S pain
for 48 hrs were included. The patients were given the option to continue
this treatment for 72 hrs or to discontinue the treatment at 48 hrs and
receive P.O. oxycodone 5 mg + acetaminophen 325 mg tabs along with
ibuprofen 400 tab every 4 hrs PRN. Two groups were identified: G I: 78
pts preferred to continue the epidural-PCA treatment; G II: 34 pts
preferred to discontinue the epidural-PCA treatment. Values are
mean±SD.
RESULTS: The groups did not differ with age, weight, height or parity.
The pts in GI received epidural infusion rate of 11.7 ± 7.0 PCA attempts
of 24 ± 41 & PCA dose of 13 ± 13 ml. In G II 26 pts (76.5%) regretted
their decision to discontinue the epidural-PCA treatment at 48 hrs.
Overall satisfactions of the pain treatments were 9.3 ± 1.6 & 7.6 ± 2.3
(p<0.00001) for G I & II respectively.
CONCLUSIONS: During 48-72 hrs following C/S most pts still
complained of pain & requested to continue the epidural-PCA
ropivacaine-fentanyl-epinephrine which provided excellent analgesia
with minimal side effects.
S-180
DOES RESPONSE TME TO INITIATEEPIDURAL ANALGESIA surveys yield valuable information and unexpected results. Although
FOR LABOR AFFECT PATIENT SATISFACTION? prompt response to requests for labor epidurals and adequate pain relief
probably contributed to the high patient satisfaction, the factors
AUTHORS: M. Megally, N. J. Joseph, X. Xie, M. Salem, S. Locher contributing to dissatisfaction were not elucidated. Expanding the scope
AFFILIATION: Advocate Illinois Masonic Medical Center, Chicago, of the questionnaire may be necessary.
IL. REFERENCES:
1. J Perinat Med. 1997;25:433;
INTRODUCTION: As part of quality improvement, we instituted a 2. Clin Obstet Gynaecol. 1998; 12:499;
patient evaluation survey designed to determine satisfaction with 3. Reg Anesth Pain Med. 2001;26:468.
anesthesia services for labor and delivery (L&D). The questionnaire
was used to determine the relationship between response time for labor Summary of Questionnaire Responses
epidural and overall satisfaction.
METHODS: All patients (n = 654) receiving epidural analgesia for Age 26.3 ± 6.2 yrs
L&D in a community hospital were surveyed for a 6 month period. The Prior discussion about pain relief Yes = 266 (70.7%) No = 110 (29.3%)
epidurals were performed by CA2 and CA3 residents supervised by an IM or IV pain meds before epidural Yes = 172 (50.3%) No = 170 (49.7%)
attending anesthesiologist using a standard technique. The
questionnaire sought information as described in the table. Response Pain prior to epidural (10 pt VAS) 8.0 ± 2.3 (0-10)
time was calculated as the interval (in minutes) between request for Pain after epidural (10 pt VAS) 2.8 ± 3.0 (0-10)
epidural and bolus injection. Estimates of pain were made according to Was response time satisfactory? Yes = 271 (73.8%) No = 96 (26.2%)
a 10 point visual analog scale (VAS).
RESULTS: Of the 446 evaluation forms returned, 53 (11.9%) were Always = 16 (4.2%) Almost Always =
rejected as incomplete or inaccurate. The remaining 393 forms were How often was pain moderate or severe 19 (5.0%) Often = 63 (16.7%) Almost
submitted for data analysis. The table summarizes the responses. Data after epidural Never = 176 (46.6%) Never = 104
in the table appears as mean ± standard deviation followed by ranges or (27.5%)
as counts followed by percent. Much More = 38 (10.1%) Somewhat
DISCUSSION: Most OB physicians (70.7%) discussed methods of Compared to expectations, how much More = 34 (9.1%) As Much = 46
pain relief during antenatal visits and half the patients recieved IM or IV pain was experienced after epidural (12.3%) Somewhat Less = 113 (30.1%)
butorphanol prior to an epidural. Epidural analgesia achieved a
Much Less = 144 (38.4%)
significant reduction in perceived pain (P < .001) and met or exceeded
patients expectations in 80.8% of patients. Following epidrual, 73% of Very Satisfied = 236 (61.8%) Satisfied =
patients experienced little or no pain following epidural. These factors 113 (29.6%) Neither = 20 (5.2%)
Overall Satisfaction
resulted in an overall satisfaction of 91.4%. Contrary to our original Dissatisfied = 5 (1.3%) Very Dissatisfied
hypothesis, we found no relationship between mean response time and = 8 (2.1%)
either timeframe satisfaction or overall satisfaction with labor epidural. Response Time 30.9 ± 20.4 min (15-185 min)
Patient satisfaction is a multifactorial issue;1-3 perhaps other factors
(primigravida/multipara, previous anesthetics, etc.) not elicited from
our survey, were also involved. In conclusion, patient satisfaction
2003; 96; S-1–S-293 S-182
S-181
PARTNER ANXIETY PRIOR TO ELECTIVE CAESAREAN the demographic variables and level of anxiety among partners. A
SECTION UNDER REGIONAL ANESTHESIA IN AN Student‘s t-test was used to determine differences in partner age in the
AMERICAN TEACHING HOSPITAL anxious and non-anxious partners.
RESULTS: Twenty-eight percent of participants demonstrated anxiety
AUTHORS: A. S. Bullough1, I. R. Taylor2, N. Naughton1, M. V. scores consistent with a pathological state. No statistically significant
Greenfield1, L. Wang1 associations between anxiety and demographic data were demonstrated.
AFFILIATION: 1University of Michigan, Ann Arbor, MI, DISCUSSION: We found the 28% figure for partner pathological
2
Southampton General Hospital, Southampton, United Kingdom. anxiety recorded in this American study to be identical with the figure
found for an equivalent study in the United Kingdom-28% [2]. The
INTRODUCTION: Over 90% of Caesarean sections at the University consistency of findings between these two observational studies
of Michigan are performed under regional anesthesia. A partner, warrants further investigation into how we can alleviate stress within
relative, or friend usually accompanies the woman, which is helpful in this covert partner population. It is possible that this anxiety may be
reducing her stress level. The aim of this study was to measure the related to personal psychological vulnerability rather than any outside
anxiety levels of the partners of women undergoing an elective factors. It is interesting to note that the general anxiety caused by the
Caesarean section with regional anesthesia and to assess whether there terrorist attacks of 9/11 (which coincided with this study) appears to
was any association between anxiety and the specific demographics of have had no effect on the level of partner pathological anxiety.
this group. REFERENCES:
METHODS: One hundred partners of women undergoing an elective [1] British Journal of Psychiatry, 128:156-65, 1976.
Caesarean section with regional anesthesia were recruited to this study [2] Anaesthesia, 57:600-605, 2002.
over a nine-month period from August 2001 to April 2002. Each partner
received both a verbal and written explanation of the study. Prior to the
surgery, partners completed a questionnaire anonymously and without
assistance (although a researcher was available to answer any
questions). The questionnaire comprised four parts: (1) demographic
data regarding age, gender, occupation, education, previous attendance
during Caesarean sections, attendance at anesthetic assessment clinics,
and relationship to patient; (2) the Leeds Self Assessment of Anxiety
(SAA) scale [1]; (3) specific questions about possible sources of
anxiety; (4) specific questions about potential relieving factors of
anxiety. Additional comments were invited for the final two sections.
The Leeds SAA scale has four possible responses to each question with
the following associated points: not at all (0), not much (1), sometimes
(2), definitely (3); possible overall scores range from a maximum score
of 18 to a minimum score of 0. The scale uses a cut-off score of 7 to
identify anxiety consistent with a pathological state. All scores were
age-corrected using a standard formula [1]. Chi-Square tests and
Fisher‘s Exact tests were used to determine differences between each of
S-182
PROSPECTIVE EXAMINATION OF EPIDURAL CATHETER
INSERTION
AUTHORS: R. Gonzalez, F. Garcia, C. Serrano, A. Cañas
AFFILIATION: Hospital Clinico San Cecilio, Granada, Spain.
INTRODUCTION: It is generally accepted that inserting epidural
catheter 4-5 cm into the epidural space minimizes complications.
Complications can occur during epidural placement for women in labor.
As many as 23% of epidural anesthesic may not provide satisfactory
analgesia. The cause of this may be technical. This study was
undertaken to determine the optimal distance that a multiorifice catheter
should be theraded into the epidural space to maximize analgesia and
minimize complications.
METHODS: Ninety healthy parturients were enrolled in this
prospective, randomized, and double-blind study. Patients were
randomly assigned to have the epidural catheter threaded 4, 6 or 8 cm
into the epidural space. After placement of the catheter and
administration of a test dose with 3 ml of 0,2% ropivacaine, an
additional 10 ml of 0.2% ropivacaine was administered. Thirty minutes
later, the adequacy of the analgesia was assessed by a blinded observer.
The incidences of intravenous cannulation, unilateral sensory analgesia,
and subsequent catheter dislodgment were recorder.
RESULTS: We found that epidural catheter insertion to 8 cm were
associated with the highest rate of insertion complications while
insertion to 4 cm was associated with the highest incidence of
satisfactory analgesia. Epidural catheters inserted 8 cm required
replacement more often than epidural catheters inserted 4 cm. Ninety-
five percent and 50% of epidural catheters that resulted in unilateral
sensory analgesia and intravenous cannulation, respectively, provided
analgesia for labor and delivery after incremental withdrawal.
DISCUSSION: For women in labor who require continuous lumbar
epidural anesthesia, we recommend threading a multiorifice epidural
catheter 4 cm into the epidural space. Additionally, epidural catheters
that result in intravenous cannulation or unilateral sensory analgesia can
be manipulated effectively to provide analgesia for labor an delivery.
S-184 2003; 96; S-1–S-293
S-183
DOES SUTURING IMPROVE THE RATE OF SUCCESSFUL complications and corrections are shown in Tables I & II. Of the 12
REACTIVATION OF LABOR EPIDURAL CATHETERS FOR failed blocks in GII, 3 occurred within 4 to 12 h (4%), 7 within 12 to 24
POSTPARTUM TUBAL LIGATION (PPTL) SURGERY? h (10%) and 2 after 24 h (3%).
CONCLUSION: Suturing the epidural catheter for labor pain
AUTHORS: S. Cohen, R. Mohiuddin, A. Prasad, N. Uzun, O. increased the success rate of reactivation of epidural block for
Soremeken, A. Cohen PPTL,and may reduce catheter movement, need for reinsertion, the
AFFILIATION: UMDNJ-Robert Wood Johnson Medical School, New incidence of one-sided anesthesia and catheter puncture of epidural
Brunswick, NJ. vessels.
REFERENCES:
92% of lumbar epidural catheters for labor pain remained in place until 1. Goodman EJ et al. Reg Anesth 23: 258 - 261, 1998
the time of PPTL surgery can be reactivated successfully until 24 h after 2. Cohen S et al. Anesthesiology 89: A1065, 1998
they have been placed1. Suturing the epidural catheter in our previous
Table 1 Catheter Movement
study2, reduced catheter movement, the need for re-insertion and Catheter
provides a high success rate of epidural blocks.
coiled
We examined whether suturing the epidural catheter to the skin can Outward Inward Dislodged
further increase the success rate of reactivation of epidural catheters for Subcut.
PPTL. (cm)
METHODS: After obtaining IRB approval and informed consent, we Group I 7(14%) 4(8%) 0.5 ± 0.7 0
studied 121 ASA I-II pts scheduled for PPTL with epidural catheter in Group II 26(36%) 13(18%) 0.2 ± 0.6 11(15%)
place. Of 2400 pts who received epidural analgesia for labor pain and Table II Incidence of Complications and Corrections
were randomized into 1200 pts who had the epidural sutured and 1200 Blood Readustme
Failed One Sided Reinsertion Catheter
that had catheter without suture, two groups were identified. GI (n=48) Vessel nt of
Block Anesthesia of Catheter Kink
had their catheters sutured upon insertion. GII (n=73) had their catheters Puncture Catheter
secured without suture. The epidural space was located at L2-3 using Group I 0 0 0 2 0 1
loss of resistance to air technique and a midline approach with the pt in Group II 12(16%)* 5(7%) 1(1%) 4(5%) 0 1(1%)
lateral or sitting flexed position. An 18 gauge, closed end B Braun Fisher's exact test, *p < 0.01
catheter was directed 5 cm cephaled and the pt’s back was unflexed. For
GI pts, the catheters were sutured with 3-0 vicryl suture at the insertion
site and then looped downward 5 cm. GII pts had their epidural
catheters looped downward 5 cm without being sutured.
RESULTS: Groups did not differ in age, weight, height, parity,
distance of epidural space from the skin, position, history of previous
neuraxial procedure, Bromage Score and maximum sensory level.
Overall satisfaction was high in both groups, 9.6±0.9 vs. 9.5±1.0 for
Groups I and II respectively. The length of catheter coiled under skin
upon removal was 0.5±0.7cm and 0.2±0.6cm ( p < 0.05 Student’s
unpaired test). The incidence of catheter movements and resulting
S-184
COMPARISON OF LEVOBUPIVACAINE 0,16% AND S- RESULTS: No differences in parturients demographics, parity,
ROPIVACAINE 0,16% COMBINED WITH SUFENTANIL induction of labor rate, total drug dose administered, duration of labor
0,5µG/ML FOR PARTURIENT-CONTROLLED EPIDURAL and delivery were observed. During PCEA, median sensory block level
LABOR ANALGESIA was T6 in both groups, maximum motor block according to the
Bromage scale (4) was 1 in both groups. At no time there was a
AUTHORS: T. Rinne1, S. Klösel1, H. A. Waibel1, B. A. Hall2, D. H. significant difference between VAScores among groups. Considering
Bremerich1 all VAScores over PCEA time, there were 72 time points in the S-
AFFILIATION: 1Dept. of Anesthesiology, Intensive Care Medicine ropivacaine group and 59 time points in the levobupivacaine group,
respectively. In the S-ropivacaine group, VAScores were greater than 40
and Pain Therapy, Frankfurt, Germany, 2Mayo Clinic, Rochester, MN. mm at 7 time points(9,7%) compared to 4 time points (6,8%) in the
INTRODUCTION: Pharmacological studies suggest that, compared to levobupivacaine group. This difference was not statistically significant.
bupivacaine, the S(-)-enantiomer levobupivacaine has equal local There was no evidence of neonatal depression.
anesthetic potency with reduced potential for cardiovascular and central DISCUSSION: Both local anesthetics combined with sufentanil
nervous system toxicity (1). S-ropivacaine is chemically homologous to provided excellent parturient satisfaction. Used epidurally for PCEA in
bupivacaine, but manufactured as the pure S-enantiomer. In vitro and in labor, levobupivacaine 0.16% had the same clinical profile as S-
vivo studies demonstrated less motor block, less central nervous and ropivacaine 0.16%when combined with sufentanil.
cardiovascular toxicity (2) and a better neonatal outcome (3) compared REFERENCES:
to racemic bupivacaine. To date, no previous study has compared the 1.Levobupivacaine. Drugs 2000;59:551
analgesic efficacy of levobupivacaine and S-ropivacaine for parturient- 2.McClure JH: Ropivacaine. British Lournal of Anaesthesia
controlled epidural analgesia (PCEA) in labor. 1996;76:300.
METHODS: After local ethics committee approval and written, 3.Writter WDR: Neonatal outcome and mode of delivery after epidural
informed consent, 40 parturients were included in the prospective, analgesia for labour with ropivacaine and bupivacaine: a prospective
randomized and double-blinded study (ASA physical status I, 31.2±5.6 meta-analysis. Brit J Anaesth 1998;81:713.
years, 167.1±5.7 cm, 79.9±11.7 kg, 39.2±1.9 weeks gestational age, 4. Bromage PR: Quality of epidural blockade. I. Influence of physical
cephalad presentation, singleton pregnancy). Epidural catheters were factors. Br J Anaesth 1964;36:342.
placed at the L2-3 interspace. The parturients were assigned to receive
either ropivacaine 0,16% or levobupivacaine 0,16% combined with means±SD S-Ropivacaine Levobupivacaine
sufentanil. Thirty minutes after administration of a priming dose Duration of labor (h) 9:24±3:28 9:06±3:53
containing 16 mg ropivacaine or 16 mg levobupivacaine plus 10 µg
Duration of PCEA (h) 2:08±2:09 2:04±1:33
sufentanil, PCEA was startet(background infusion 6 mL/h, lock-out
time 20 min, bolus 3 mL, 0.5 µg sufentanil). The intensity of pain Cumulative local anesthetic dose administered
(mg) 53.3±22.1 50.7±21.4
(visual analog scale, VAS, range 0-100 mm) as well as total drug dose
administered, duration of labor and delivery, sensory and motor block Cumulative sufentanil dose administered (µg) 16.7±6.9 15.9±6.7
characteristics, maternal satisfaction with the degree of pain relief and Maternal satisfaction with the extend of pain
neonatal outcome (Apgar-score, umbilical cord blood analysis) were relief (%) 100% 100%
determined. Data are expressed as mean ± SD, a P-value of<0,05 was
2003; 96; S-1–S-293 S-186
S-185
LEVOBUPIVACAINE COMBINED WITH FENTANYL Spinal block characteristics for the 2 study groups
ADMINISTERED INTRATHECALLY FOR CESAREAN
LB (n=14) RB (n=10)
SECTION: A COMPARISON WITH RACEMIC BUPIVACAINE
Highest dermatome reached T3 T2
AUTHORS: J. Chiu, J. W. Tan, A. T. Sia, I. S. Yeo, H. Tan Time to reach highest dermatome (min) 9+/-2 12+/-4
AFFILIATION: KK Women's & Children's Hospital, Singapore,
Time to Bromage 3 (min) 7+/-3 6+/-3
Singapore.
Time to regression to T10 (min) 146+/-29 175+/-38
INTRODUCTION & OBJECTIVE: Hyperbaric intrathecal (IT) L- 155+/-25*
bupivacaine(LB) has been shown to exhibit equivalent clinical efficacy Time to regression to Bromage 0 (min) 86+/-26
to racemic bupivacaine (RB) in doses from 4 to 12 mg among healthy (p<0.05)
volunteers (1). For facilitating elective cesarean section, it has been Time to 1st sensation of pain (min) 108+/-28 140+/-32
recommended that IT LB 10-12.5mg could substitute for RB (2). The Time to 1st request for analgesics (min) 910+/-147 284+/-87
aim of this study was to compare IT LB with RB (both with added IT
fentanyl) in parturients undergoing elective cesation section under Satisfaction score (VAS 0-100) 89+/-8 91+/-7
spinal anesthesia.
METHODS: In this ongoing prospective, double-blinded trial, 24
patients has since been randomized to receive either hyperbaric 0.5%
LB 9 mg + fentanyl 10 mcg (Group LB, n=14) or 0.5% RB 9 mg +
fentanyl 10 mcg (Group RB, n=10). Sensory block (loss of pinprick
sensation), motor block (modified Bromage scale), analgesic
characteristics and post-block complications were evaluated. Statistical
analysis comprised the Student's t-test, Wilcoxan ranked-sum test and
Newman-Keuls test for post hoc comparison.
RESULTS: Patient characteristics in the 2 groups were not statistically
significant. The time to regression of motor block to Bromage 0 was
significantly shorter for LB compared to RB (146+/-29 min; 95% CI of
72-100 min vs. 155+/-26 min; 95% CI 137-179 min respectively). In
addition, 3 (21%) patients in the LB groupdid not achieve a Bromage 3
score whereas all RB patients did.
CONCLUSION: The combination of 0.5% bupivacaine 9 mg (either
LB or RB) with fentanyl 10 mcg provided for satisfactory analgesia in
all study subjects. LB resulted in a faster resolution of lower limb motor
power which may facilitate earlier postoperative ambulation.
REFERENCES:
(1) Anesth Analg 2002;94:188-93
(2) Anesthesiology 2001;95:A1031
S-186
BACKGROUND INFUSION ADDED TO PARTURIENT demand differed not significantly among groups. Mean PCEA-solution
CONTROLLED EPIDURAL ANALGESIA DURING LABOUR consumption in group 1 was 14.6 ± 7.3mL and in group 2 27.4 ±
AND DELIVERY - IS LESS MORE? 14.9mL, being significantly higher (p=0.0018).
AUTHORS: H. A. Waibel1, S. Petrich2, T. Rinne1, B. A. Hall3, D. H. means ± SD Group 1 Group 2

Bremerich1 duration of PCEA [min] 182.4 ± 132.58 205.35 ± 129.83 n.s.
AFFILIATION: 1Dept. of Anesthesiology, Intensive Care Medicine cumulative sufentanil dose
and Pain Therapy, JW Goethe University Hospital, Frankfurt, Germany, [µg] 7.32 ± 3.65 13.72 ± 7.45 0.0018
2
Dept. of Obstetrics and Gynecology, JW Goethe University Hospital, Apgar Score at 10mins 9.3 ± 0.3 9.8 ± 0.5 n.s.
Frankfurt, Germany, 3Mayo Clinic, Rochester, MN.
satisfaction with the extent
of pain relief [%] 100 100 n.s.
INTRODUCTION: The use of a continious background infusion
during parturient controlled epidural analgesia (PCEA) seems to reduce
breakthrough pain [1, 2] during labor. Currently, 25 - 30% of the DISCUSSION: Although both regimens provided excellent pain
maximum dose as a continuous background infusion are recommended control during labor and delivery, increasing the background infusion
[1]. This study was designed to determine whether a 40% backround rate to 40% conferred no benefit. The regimen using less PCEA-
infusion results in less pain peaks than 25%. solution yields identical results with respect to overall parturient
METHODS: After local ethics committee approval and written, satisfaction and pain relief. There was no evidence of neonatal
informed consent, 40 parturients were included in this study (ASA depression.
physical status I and II, >37 weeks gestational age, singelton pregnancy, REFERENCES:
cephalad presentation). After placement of an epidural catheter and 1. The role of continuous background infusions in patient-controlled
administration of an initial bolus containing 16mg ropivacaine plus 10µg epidural analgesia for labor and delivery. Anesth Analg 1994;79:80-84
sufentanil, parturients were prospectively randomized into two groups. 2. Continuous background infusion plus demand dose is superior to
The PCEA-solution consisted of ropivacaine 0.16% plus 0.5µg/ml demand - only parturient-controlled analgesia (PCEA) for labor and
sufentanil. Group 1 received PCEA with 4mL/h background infusion delivery IARS 76th Clinical & Scientific Conference 2002, Abstract
plus an hourly maximum of 4 x 4mL boli on demand. Group 2 received S193
PCEA with 6mL background infusion plus an hourly maximum3x3ml
boli on demand. The intensity of pain (verbal analog scale VAS, range
0-100) as well as the overall drug doses administered, duration of labor
and delivery, sensory and motor block characteristics, maternal
satisfaction with the extent of pain relief and fetal outcome (Apgar-
score, umbilical cord blood analysis) were determined at 30 and 60 min
after start of PCEA and then hourly until delivery.
RESULTS: Demographics as well as duration of labor and delivery as
well as sensory and motor block characteristics were comparable
among groups. Pain peaks (VAS 40) in group 1 occurred at 6 of 91 time
points (6.6 %) and in group 2 at 5 of 86 time points (5.8%). Bolus
2003; 96; S-1–S-293
S-187
STATION OF THE PRESENTING PART VS CERVICAL
DILATATION AT THE TIME OF EPIDURAL BLOCK AS
PREDICTORS OF CESAREAN DELIVERY
AUTHORS: S. Ramanathan
AFFILIATION: Magee-Womens Hospital, Pittsburgh, PA.
Epidural analgesia is implicated in increasing cesarean section (C.S).
This reports whether the station of the fetal vertex or cervical dilataton
at the time of epidural block is more frequenetly associated with
cesarean section (C.S) section for dystocia.
The report is based on quality assurance database: Inclusion criteria:
healthy parturients, nulliparity,singleton vertex presentation, oxytocin
augmentaion, epidural analgesia with continuous infusion, birth weight
>2.5 Kg. Results were expressed as mean (SD) and analyzed using X2
and logistic regression tests. Cervical dilatation and station of the vertex
(-2, -1, 1 +1) were noted. A totalof 1554 parturients were included. No
association between was seen between cervical dilatation and C.S..
However, C.S. was most likely to happen in patients at -2 station and
least likely at +1 station (p=0.00002,Odds ratio for the range 9.8, Fig 1)
The C.S. rate for dystocia was the highest at -2 station and the lowest at
+1 (Table 1).
Our data show that the station of the presenting part in relation to the
iliac spines is a btter predictor of C.S than cervical dilatation at the time
of epidural block. This factor must be considered when evaluationg the
effect of epidural analgesia on C.S rate.
Station vs C.S. rate

Cervical
Station Total cases (n) C.S.% p vs Station -2
Dilatation (cm)
-2 3.2(1.34) 209 26,8%
-1 3.44 (1.23) 718 16.8 0.002
0 4 (1.72) 573 12.7 0.000
+1 4 (0.63) 54 9.2 0.01
Pain – Basic Science
Pain - Basic Science

S-189 2003; 96; S-1–S-293
S-188
DEVELOPMENT OF A PRIMATE BEHAVIORAL heating are mediated by C fiber activation, whereas responses to high
NOCICEPTIVE ASSAY rate heating are mediated by A- activation. The principles determined in
rodents with regards to differential testing of A- and C fiber mediated
AUTHORS: Y. Lu1, C. Laurito1, G. Pappas1, G. Votta-Valis1, D. nociception are also applicable to the testing of non-humen primates.
Yeomans2
This primate nociceptive assay allows for differentiation of different
AFFILIATION: 1University of Illinois, Chicago, IL, 2Stanford
elements of pain state and for better predictions of the clinic utility of
University, Stanford, CA.
novel approaches to the treatment of pain.
INTRODUCTION: Lacking the pain assessment tools that could REFERENCES:
differentiate different elements of a pain state would considerably 1. Pain 2002; 97:183-187.
hamper the ability to evaluate a distinct treatment outcome in the 2. Pain 1996; 68:133-140.
clinical setting(Mao J, pain 2002). We have established a rodent assay 3. Pain 1996; 68: 141-150
which allow for the separate assessment of nociceptive responses
mediated by the activation of myelinated(A-) or unmyelinated (C) pain
afferents (Yeomans, pain1996). However, prior to attempting novel
analgesic treatment in humans, it is important to determine whether
similar effects exists in non-human primates. This study is to develop a
primate behavioral nociceptive assay such that we are able to separately
assess heat-evoked withdrawal responses mediated by the two afferent
types in stump-tailed macaques.
METHOD: Stump-tailed macaques were lightly anesthetized with IV
propofol. Foot withdrawal latencies evoked by high (6.5 degree C/sec-
A-) or low (0.9 degree C/sec-C fiber)rate radiant heating of the dorsum
of the hindpaws are assessed. In some cases, the skin of the hindpaw are
then treated topically with a solution of capsaicin which preferentially
sensitize C fiber afferents. in some sessions, cumulative dose response
for IV morphin are generated, as systemic morphin preferentially
attenuate C, as opposed to A- mediated nociception.
RESULTS: The evoked foot withdrawal latencies similar to those
observed in rats for both high (2-3 sec) and low (10-12 sec) heating
rates. Capsaicin preferentially decreased foot withdrawal latencies for
responses to the low rate heating. Morphin preferentially affected low
vs. high rate heating responses.
DISCUSSION: In a non-human primate, responses to low rate skin
S-189
ANALGESIC DRUG SENSITIVITY IN A NEW RAT MODEL OF With the rib-retraction model allodynia was seen in 40% of the animals
POST-THORACOTOMY PAIN after 60 min of retraction, but only 17% when the retraction time was
reduced to 30 min. Allodynia appeared by Day 9 in both the CCI and rib
AUTHORS: J. S. Kroin, A. Buvanendran, S. K. Nagalla, K. J. Tuman, retraction models, and lasted at least 42 days. Morphine at 3 mg/kg, but
A. D. Ivankovich not 1 mg/kg, and gabapentin at 50 mg/kg, but not 25 mg/kg, reduced
AFFILIATION: Dept. of Anesthesiology, Rush Medical College, allodynia (Fig.).
Chicago, IL. DISCUSSION: Rib-retraction in rats for 60 min produces a similar
mechanical allodynia as in the CCI model. Allodynia in either model is
INTRODUCTION: The incidence of long-term pain after thoracotomy sensitive to both morphine and gabapentin. Since rib-retraction in
is 50% (1), usually along the distribution of the intercostal nerves. A patients has been shown to affect intercostal nerve function, this new
recent clinical study has shown that rib retraction alone caused model presented here may be useful for devising techniques to treat and
conduction block in the intercostal nerves on both sides of the retractor reduce long-term pain.
(2). In addition, a chronic pain syndrome can be produced in rats by REFERENCES:
inducing a chronic constriction injury (CCI) to the intercostal nerves (1) Anesthesiology 2000;93:1123.
with chromic gut sutures (3). The present study describes a combined (2) Eur J Cardiothor Surg 2002;21:298.
rib-retraction/thoracotomy model and compares it to the CCI model. (3) Can J Anesth 2001;48:665.
The effect of morphine or gabapentin on the mechanical allodynia
elicited in these models was also tested.
METHODS: Following Animal Care Committee approval, male
Sprague-Dawley rats were anesthetized with isoflurane and the right 4th
and 5th ribs exposed. For the rib-retraction model, the pleura was opened
between the 2 ribs and a small self-retaining retractor placed under the
ribs and opened 8 mm. The retractor was left in place for 30 or 60 min.
During this time, ventilation was mechanically assisted. For the CCI
model, the pleura was also opened and 4-0 chromic gut sutures were
loosely placed around the 4th and 5th intercostal nerves. At the
completion of the surgery, air was aspirated from the pleural cavity
before suturing the wounds. Starting at Day 2 post-surgery, animals
were tested for mechanical allodynia using calibrated von Frey
filaments applied to the dorsal skin around the incision site (3). Two
weeks after surgery, animals were tested for reduction of allodynia with
intraperitoneal injections of morphine sulfate 1-3 mg/kg or gabapentin
25-50 mg/kg. Responses pre- and post-injection were compared with
the Wilcoxon signed-rank test.
RESULTS: With the CCI model, mechanical allodynia (withdrawal
threshold < 4 gm) occurred in 60% of the animals, which is similar to
the incidence reported in the original description of the CCI method (3).
2003; 96; S-1–S-293 S-191
S-190
INFLUENCE OF POST-OPERATIVE PAIN ON SPINAL animals. In the kaolin-carrageenan animals (positive inflammatory
CYCLOOXYGENASE-2 (COX-2) IN RATS control), COX-2 protein increased 1.44-fold.
DISCUSSION: This is the first study to demonstrate that post-
AUTHORS: J. S. Kroin1, Z. D. Ling2, A. Buvanendran1, S. DeLange1, operative pain leads to an increase in COX-2 protein levels in the
K. J. Tuman1 lumbar spinal cord. We have previously demonstrated that a spinally
AFFILIATION: 1Dept. of Anesthesiology, Rush Medical College, administered COX-2 inhibitor contributes to pain relief in the same
Chicago, IL, 2Dept. of Pharmacology, Rush Medical College, Chicago, post-operative pain model (5) suggesting that COX-2 inhibitors
IL. delivered neuraxially may can have a role in the treatment of post-
operative pain.
INTRODUCTION: Peripheral inflammation elicits up-regulation of REFERENCES:
COX-2 (but not COX-1) mRNA and protein in the spinal cord (1,2). (1) Br J Pharm 1997;120:71P.
However, it is not known whether there are similar changes in spinal (2) Nature 2001;410:471.
COX-2 following surgical incision. We have performed experiments (3) Pain 1996;64:493.
with normal rats and rats 6 h after foot-incision surgery to determine if (4) Neuroscience 1999;93:775.
changes of COX-2 protein occur in the lumbar spinal cord (5) Reg Anesth Pain Med 2002 (in press).
postoperatively. The COX-2 protein was also compared to another
group of rats who developed inflammation.
Sprague-Dawley rats (300 g) were anesthetized with isoflurane, a 1 cm
long incision made in the skin and plantaris muscle of the plantar
hindfoot bilaterally, and then animals allowed to recover from
anesthesia. This model produces post-operative pain within a few hours
of the incision (3). Six hours after incision animals were sacrificed and
the spinal cord rapidly ejected from the spine using a syringe with cold
saline. The L3-L6 spinal cord segment was dissected free and quick-
frozen. Spinal cords were also removed and dissected from normal
control rats, as well as from a third group of animals that had kaolin-
carrageenan injected into the knee, a technique known to produce an
increase in COX-2 protein levels (4). The spinal cord sections were
homogenized in lysis buffer and prepared for Western blot analysis. The
total protein of each sample was adjusted to 2 mg/mL. Films were later
analyzed with densitometry and experimental animals were compared
to unoperated controls.
RESULTS: Western blot analysis of spinal cords showed two bands
around 72 kD alongside that of the purified COX-2 protein standard
(Fig.). In the foot incision animals, the optical density of the COX-2
protein band was increased 1.33-fold as compared to the control
S-191
OPIOID SENSITIVITY IN A RAT MODEL OF ADHESIVE
LUMBAR ARACHNOIDITIS
AUTHORS: A. Buvanendran, J. S. Kroin, S. K. Nagalla, K. J. Tuman,
A. D. Ivankovich
AFFILIATION: Dept. of Anesthesiology, Rush Medical College,
Chicago, IL.
INTRODUCTION: Arachnoiditis is an intractable condition that is a
known sequala of spinal surgery. Lumbar laminectomy in rats has been
shown to produce adhesions around the lumbar-sacral nerve roots,
especially with extradural kaolin application, and to produce pain
related behavior in rats (1,2). The response to analgesic therapy,
including opioids, is often equivocal in patients with post-surgical
arachnoiditis, and there has been no systematic evaluation of opioid
analgesia for this condition. In this study, we evaluated the rat post-
laminectomy model as a method for testing pain responses after
systemic opioid administration.
Sprague-Dawley rats (300-350 g) were anesthetized with isoflurane and
a laminectomy performed at the L5 and L6 vertebral level. Sterile Morphine at both doses improved time on the rotating rod (from 174 to
kaolin powder, 5 mg, was applied to the epidural space. After 5 min, the 244 sec at 1 mg/kg; from 176 to 256 sec at 3 mg/kg).
wound was closed. Animals were monitored twice weekly for DISCUSSION: Systemic morphine improved ambulation in rats with
emergence of pain-related behavior: ambulation (rotating rod, 15 rpm, adhesive lumbar arachnoiditis, and also reduced the pain response to
300 sec max); pain response to movement (number of vocalizations in hip extension. This model should be useful for evaluating the efficacy
response to 5 consecutive extensions of the hindleg, average of left and of other drug treatments for post-laminectomy arachnoiditis.
right). After 6 weeks post-operatively, morphine sulfate (0.5 mL, i.p.) at REFERENCES:
either 1 or 3 mg/kg was administered and pain related behavior (1) Spine 1993;13:1774.
reevaluated 30 min later. Data were analyzed using the Wilcoxon (2) Anesthesiology 2002;97:A720.
signed-rank test.
RESULTS: Prior to surgery, all animals could remain on the rotating
rod for 300 sec. At 6 weeks after the laminectomy, none of the animals
could ambulate for the full 300 sec. Before surgery, rats did not vocalize
when their hindleg was extended. At 6 weeks post-surgery, the animals
vocalized 1.9 times out of 5 extensions. Morphine administration
decreased the pain response to hip movement at 3 mg/kg, but not 1 mg/
kg (Fig.).
S-193 2003; 96; S-1–S-293
S-192
SPINALLY MEDIATED ANALGESIC INTERACTION Tail flick Formalin phase1 Formalin phase2
BETWEEN CLONIDINE AND BUPIVACAINE IN ACUTE
0.29 0.15 0.16
THERMALLY OR INFLAMMATORY INDUCED PAIN IN Clonidine
(0.19-0.41) (0.09-0.21) (0.09-0.23)
RATS
7.1 5.7 3.2
Bupivacaine
AUTHORS: T. Nishiyama, K. Hanaoka (3.9-10.5) (2.5-8.1) (1.7-5.1)
AFFILIATION: The University of Tokyo, Tokyo, Japan. Combination 0.11* 0.009* 0.012*
INTRODUCTION: Intrathecal clonidine, an 2 adrenergic receptor (Clonidine) (0.06-0.17) (0.002-0.014) (0.004-0.02)
agonist, showed synergistic analgesia with lidocaine in the tail-flick test Combination 2.82* 0.25* 0.31*
in rats.1 However, no studies were seen of the interaction between (Bupivacaine) (1.74-4.35) (0.08-0.33) (0.09-0.41)
clonidine and local anesthetic in chronic or inflammatory pain. In
addition, clinically bupivacaine is more often used than lidocaine in *: P < 0.05 vs. the value of each single agent.
intrathecal or epidural analgesia because of longer duration of action. Agitation, allodynia, motor disturbance and/or flaccidity were observed
Therefore, we investigated the analgesic interaction between in the rats received clonidine or bupivacaine alone. However, the
intrathecally administered clonidine and bupivacaine in inflammatory combination with the doses tested did not induce any observable side
pain as well as acute thermal pain using rats. effects.
METHODS: Sprague-Dawley rats (300 – 350 g) with lumbar DISCUSSIONS: Intrathecal administration of the combination of
intrathecal catheters were tested for their thermal tail withdrawal clonidine and bupivacaine had significant synergistic analgesia for
response using the tail flick test and for their paw flinches by acute thermal or inflammatory induced pain in comparison with each
subcutaneous formalin injection into the hind paw after intrathecal single agent alone with decreasing motor disturbance and behavioral
administration of clonidine (0.1 – 3 g) or bupivacaine (1 – 100 g). side effects in rats. These combinations might be useful in human pain
Saline was used as a control. The effects of the combination were also management.
tested by an isobolographic analysis using ED50 (50% effective dose) REFERENCE:
1. Anesthesiology 87, 436-448, 1997
values. Behavioral side effects and motor disturbance were also
examined. Eight rats were used in each dose group.
RESULTS: ED50 values (g) are shown. ( ): 95% confidence interval.
S-193
CLINICAL AND EXPERIMENTAL EVALUATION OF THE RESULTS: TOF showed 90% reduction from the control which
MUSCLE RELAXANT EFFECT OF NEFOPAM HCL(A NON- represent muscle relaxation, satisfactory for the surgery, in all cases and
NARCOTIC ANALGESIC) reversal at the end of the procedure was complete after prostigmine
injection. There was no re-curarization and the mean postoperative tidal
AUTHORS: R. Michael1, N. Younan2, F. Fam1, A. R. Abadir1 volume record was near to the preoperative one after prostigmine
AFFILIATION: 1The Brookdale University Hospital and Medical injection. Isolated animal study revealed that Nefopam HCI in a dose of
Center, Brooklyn, NY, 2Faculty of Medicine- Cairo University, Cairo, 0.25-20 g/kg had no effect on height of contraction of cat gastrocnemius
Egypt. muscle. In vivo studies using rat phrenic nerve diaphragms and Toad's
rectus abdominis muscle showed that small doses of Nefopam HCI (I0g
INTRODUCTION: Nefopam HCL is a potent non-opiate analgesic- to 640.g/50 ml bath) had no effect on the diaphragmatic response to
that is chemically and pharmacological unrelated to any class of drugs nerve stimulations, while large doses of Nefopam HCI (1000-3000 g/50
presently known in analgesia. The mechanism of its analgesic action is ml bath) resulted in a dose related reduction in response to indirect
not clear. It may potentiate the effect of some biogenic amines -have a stimulation with complete cessation 4 min. after addition of 3000 g/50
weak atropine like action or may be a weak central nervous system ml bath. Prostigmine 250 g/50 ml bath failed to prevent neuromuscular
stimulant. Nefopam possesses apparent muscle relaxant activity 5-10 block caused by Nefopam HCI.
times as potent as orphenadrine (1). However in contrast to this muscle CONCLUSION: We concluded that Nefopam HCI offers adequate
relaxant property, it was reported that Nefopam HCL enhanced spinal non-narcotic analgesia with a good muscle relaxant effect.
motor neurone excitability and recovery and heightened stretch and REFERENCES:
flexion reflexes-in man. The aim of this study is to determine and 1. Glaser R, Donnell D, Maartmann-Moe K. J Pharm Sci. 1992
evaluate the muscle relaxants effect of Nefopam HCL. Sep;81(9):858-62
Table of Contents
METHODS: Clinical Study was carried out on 15 adult patients under
going major abdominal surgery. Preparation of the hand with
application of myotest (myograph 2000 Bioameter) was done.
Continuous automatic record during the operation was done using
traction transducer on the hand and setting up the apparatus. Nefopam
HCL in a dose of 0.3-0.5 mg/kg was added to the IV infusion drip.
Observation of the patient for the degree of relaxation in relation to the
dose of Nefopam was done until a 90% reduction of the twitch was
obtained by continuous recording of TOF. Patients were observed for
the next 4 hours post operatively.
Experimental study of the neuromuscular transmission was carried out
in vivo by using the gastrocenemius sciatic nerve preparation of 10
anesthetized cats. In vitro studies were done using isolated rat pherenic
nerve diaphragm preparation and isolated Toad‘s rectus abdominis
muscle.
2003; 96; S-1–S-293
S-194
MECHANICALLY ACTIVATED ION CHANNELS IN PAIN representing individual subpools were microinjected into oocytes and
TRANSDUCTION screened for mechanically induced inward current responses.
RESULTS: Hypertonic conditions elicited inward current responses in
AUTHORS: M. A. Schumacher1, H. Eilers2 oocytes injected with a DRG cRNA library subpool greater than that
AFFILIATION: 1University of California, San Francisco, San observed in water injected oocytes. Additional characterization is
Francisco, CA, 2University of California San Francisco, San Francisco, underway. 3) Utilize alternative cloning strategies (differential display)
CA. to isolate candidate cDNAs that mediate mechanotransduction in
nociceptors.
INTRODUCTION: Currently, side effects limit the ability to manage RESULTS: We have cloned, sequenced and partially characterized
acute and chronic pain states even if adequate pain relief has been LRP157, a mRNA binding homologue that is regulated by NGF in
achieved. Since the majority of pain originates in the periphery through nociceptors. We are testing the hypothesis that LRP157 binds to the 3'
the activation of primary afferent neurons that detect noxious stimuli UTR of mRNA expressed in nociceptors and functions as a stability
(nociceptors), therapies that selectively block nociceptor activation factor.
could potentially block pain signaling at its origin. Our research CONCLUSION: Using a combination of approaches including
supported by the IARS is focused on investigating the molecular basis characterization of cultured primary sensory neurons activated by cell
by which mammalian organisms detect noxious mechanical stimuli. shape change, expression cloning, and differential display cloning
This new direction builds on previous work that led to the isolation of techniques, we hope to isolate nociceptor specific ion channels and
the "capsaicin receptor" now termed, vanilloid receptor subtype -1. associated proteins that transduce or regulate mechanically induced
Although "VR1" is activated by multiple noxious stimuli including pain and hyperalgesia.
products of inflammation and heat, it is insensitive to mechanical Supported by a grant from the International Anesthesia Research
changes in membrane shape as occurs under either hypertonic (cell Society.
shrinkage) or hypotonic (cell stretch) conditions. Our initial aim is to
test the hypothesis that: Ion channels activated by cell shrinkage
function to transduce noxious mechanical stimuli in nociceptors. Thus
far, we have focused on three main objectives: 1) Establish primary
cultures of dorsal root ganglion (DRG) neurons to serve as a model
system to characterize electrophysiologic and intracellular calcium
responses following cell shrinkage or swelling under control /
inflammatory conditions.
RESULTS: Using calcium-imaging techniques, primary cultures of rat
sensory neurons showed a decrease in intracellular calcium in response
to cell shrinkage whereas cell swelling produced an increase in
intracellular calcium. 2) Constitute a high quality cDNA library derived
from rat DRG to be used for cloning of mechanosensitive ion channels.
RESULTS: We have completed the subdivision of a rat sensory
ganglion cDNA library with 140 individual pools containing
approximately 10,000 recombinants /pool. In vitro RNA transcripts
Pain – Clinical
Pain - Clinical
S-196 2003; 96; S-1–S-293
S-195
EFFECT OF CELECOXIB PREMEDICATION ON RECOVERY period. However, even the 400 mg dose of celecoxib failed to facilitate
AFTER OUTPATIENT SURGERY: A DOSE RANGING STUDY the recovery process after outpatient ENT surgery
REFERENCES:
AUTHORS: A. Recart, K. Klein, P. F. White, T. Issioui, M. Shah 1. Issoui T, Klein K, White PF: The efficacy of premedication with
AFFILIATION: Department of Anesthesiology and Pain Management celecoxib and acetaminophen in preventing pain after otolaryngologic
University of Texas Southwestern Medical Center, Dallas, TX. surgery. Anesth Analg 2002;94:1118-93
2. Reuben S, Connelly NR: Postoperative analgesics effects of
INTRODUCTION: Celecoxib, a cyclooxygenase-2 (COX-2) inhibitor, celecoxib or rofecoxib after spinal fusion surgery. Anesth Analg
has been reported to be comparable to acetaminophen1 but less effective 2000;91:1221-5
than rofecoxib2 in the prevention of pain after surgery. However, these
early studies evaluated a 200 mg dose of celecoxib. Recently, the FDA Control Celecoxib Celecoxib
increased the celecoxib dosage recommendation to 400 mg for acute (Placebo) (200 mg) (400 mg)
pain management. To date, no studies have directly compared the Age (yr) 45±13 40±14 42±15
analgesic efficacy of different doses of celecoxib for the prevention of
postoperative pain. This prospective, double-blind placebo-controlled Anesthesia time (min) 90±36 90±40 87±43
study compared oral celecoxib 200 mg to 400 mg when administered PACU stay (min) 67±24 61±26 62±26
for premedication of outpatients undergoing minor ENT surgery. Actual discharge (min) 138±46 127±26 118±48
METHODS: 95 healthy outpatients undergoing nasal and sinus surgery
were assigned to one of three study groups: Control (Placebo, n=31), Peak Pain Score (n) 5 (2-10) 4 (0-8) 4 (0-7)
Celecoxib 200 mg (n=30), or Celecoxib 400 mg (n=33). The study drug Patients with severe pain (%) 26 23 9*
was given orally 30-45 min prior to surgery and all patients received a Fentanyl rescue (g) 118±85 74±67 59±60*
standardized general anesthetic technique. During the postoperative
period, recovery times, the need for rescue analgesics, quality of Oral pain medication (n) 2±3 2±2 1±2
recovery (0-100), patient satisfaction with pain management (0-100) Peak pain score at home 2 (0-10) 2 (0-6) 2 (0-5)
and side effects were recorded. Pain was assessed using a verbal rating * p < 0.05 vs Control t p < 0.05 vs celecoxib 200 mg
scale (VRS) with 0=none to 10=maximal in the Phase I (PACU) and II
(DSU) recovery areas and at 24 hr. after surgery.
RESULTS: Celecoxib, 400 mg PO, was significantly more effective
than placebo in reducing postoperative pain and the need for opioid
analgesic medication. Although celecoxib 400 mg was more effective
than celecoxib 200 mg in reducing the incidence of severe pain
(VRS>6), no differences were observed between the study groups with
respect to recovery times and outcome variables during the
postdischarge period.
CONCLUSIONS: Oral premedication with celecoxib 400 mg was
more effective than 200 mg in reducing severe postoperative pain and
the need for rescue analgesic medication in the early postoperative
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ROLE OF SELECTIVE CYCLOOXYGENASE-2 INHIBITORS DISCUSSION: Non-incisional post thoracotomy pain is common and
IN REDUCING NON-INCISIONAL POST-THORACOTOMY can be severe. The cause is not completely understood but various
PAIN. mechanisms including pleuritic chest pain, phrenic nerve stimulation
and positioning related stretch of shoulder girdle has been implicated.
AUTHORS: M. A. Munir, M. Jaffar, C. S. Pablo, J. Zhang Diffuse nature of this pain makes it difficult to treat with epidural
AFFILIATION: University of Arkansas for Medical Sciences, Little narcotics and local anesthetics. Ketoroalc, a non-selective
Rock, AR. cyclooxygenase enzyme inhibitor has been shown to be effective in
treatment of non-incisional pain1. Our experience, suggests that
INTRODUCTION: Non-steroidal anti-inflammatory drugs (NSAIDs) rofecoxib, a selective cyclooxygenase 2 inhibitor is effective in
may be used to treat acute postoperative pain. NSAIDs inhibit the treatment of NIPT pain and may reduce PCEA requirements and
cyclooxygenase enzyme, reduce prostaglandin synthesis and alleviate associated side effects. Placebo control, double-blinded studies are
inflammatory pain. Ketorolac has been used successfully to treat non- needed to further study the role of rofecoxib in thoracotomy patients. .
incisional post-thoracotomy (NIPT) pain (pleuritic chest pain, joint REFERENCES:
pain, shoulder tip pain)1. Selective cyclooxygenase 2 (COX-2) Anesthesia & Analgesia. 84(3):564-9, 1997
inhibitors may reduce NIPT pain. We report a series of nine patients in
whom rofecoxib, a COX-2 inhibitor reduced NIPT and patient
controlled epidural analgesia (PCEA) requirements.
METHODS: Six patients had lung resection, one had Nissen
fundoplication and two had thoracoscopy. Thoracic epidural catheters
were placed preoperatively in all patients. All patients received a
combination of levobupivacaine 0.075% and hydromorphone 0.001%
via epidural catheter. Verbal analogue scale (VAS) was used to evaluate
patients for incisional and NIPT pain. Patients were evaluated by acute
pain team immediately after surgery and twice daily afterwards.
Epidural infusion rate was increased if patients had incisional pain.
NIPT pain was treated with rofecoxib 50-mg orally once a day.
RESULTS: Epidural infusion was strarted in operating room.
Immediately after surgery, epidural infusion was adjusted so as to
reduce the incisional pain socre. On post-operative day one no patient
had significant incisional pain (VAS= 0-2), however all patients
complained of moderate to severe NIPT pain (VAS= 6-9). Patients who
received rofecoxib 50mg orally, showed remarkable improvement in
NIPT pain during evening evaluation. Patients had either complete
relief (VAS=0 in seven patients) or more than 50% improvement (VAS=
3-4) within 12 hours of rofecoxib administration. On post-operative day
two PCEA bolus requests were reduced by 60-80%.
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ORAL DEXTROMETHORPHAN PREMEDICATION RESULTS: VAS and VRS scores were similar among the 3 groups
REDUCED POSTOPERATIVE ANALGESIC CONSUMPTION during the study period, respectively. Total postoperative analgesic
IN PATIENTS FOLLOWING UNILATERAL MANDIBULAR consumption was significantly less in Group A than in Group C (Figure
THIRD MOLAR EXTRACTION UNDER LOCAL ANESTHESIA 1, p<0.05).
DISCUSSION: The results of this study shows that small dose
AUTHORS: T. Aoki1, H. Yamaguchi2, H. Naito3 dextromethorphan showed preemptive analgesic effect after unilateral
AFFILIATION: 1Tokai University School of Medicine, Isehara, Japan, mandibular third molar extraction under local anesthesia. The reduced
2
Ryugasaki Saiseikai Hospital, Ryugasaki, Japan, 3Iwaki Kyoritsu postoperative analgesic requirement brings patients major benefits in
terms of the reduced incidence of the adverse effects induced by
General Hospital, Iwaki, Japan. analgesics and the reduced cost. In conclusions, dextromethorphan
INTRODUCTION: In order to prevent posttraumatic pain premedication did not improve VAS and VRS scores, but reduced an
accompanying surgery, preoperative NMDA antagonists have been analgesic consumption compared with control group.
tried with a certain preferable effects, and which effect is called REFERENCES:
preemptive analgesia. Dextromethorphan is one of NMDA receptor 1. Anesth Analg 92: 739-44; 2001.
antagonists and is reported to show preemptive analgesic effect when 2. Anesth Analg 89: 748-52; 1999.
used in large doses (1, 2). And it has not been reported if
dextromethorphan premedication has preemptive analgesic effect when
it is used in small dose and in a dental surgery under local anesthesia. In
this study, we tested if small dose dextromethorphan premedication
might produce preemptive analgesic effect in patients undergoing
unilateral mandibular third molar extraction under inferior alveolar
nerve block using a local anesthetic.
METHODS: The study protocol was approved by the local ethical
committees. Consecutive 111 ASA physical status I or II patients who
underwent unilateral mandibular third molar extraction surgery were
enrolled in this study, and were allocated into 3 groups. Group A (n=37)
and B (n=38) patients were given dextromethorphan, 30 mg, and
diclofenac, 25 mg, orally before surgery, respectively. Group C patients
(n=36) were not premedicated. Surgery was completed within 30 min
under inferior alveolar nerve block using a local anesthetic.
Postoperatively the patients were allowed to take oral diclofenac, 25
mg, each time when they needed for postoperative pain relief.
Postoperative pain was evaluated at the clinic on the first, 7th, 14th and
28th day after surgery, respectively, using visual analog scale (VAS) and
verbal rating score (VRS). VAS, VRS and the number of diclofenac per
a day they took were compared among the groups using Mann-Whitney
U-test with statistical significance of p<0.05.
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PRE-ADMINISTRATION OF LOW-DOSE KETAMINE T0,P<0.05) in the saline trial, while it showed no change throughout the
ATTENUATES TOURNIQUET PAIN IN HEALTHY time course in ketamine trial. The concentrations of CAs showed no
VOLUNTEERS change in either trial.
CONCLUSIONS: We conclude that pre-administration of low-dose
AUTHORS: M. Takada1, M. Fukusaki1, Y. Terao1, M. Kanaide1, K. ketamine attenuates tourniquet pain and prolongs tourniquet time in
Yamashita1, K. Sumikawa2 healthy volunteers. The activation of NMDA receptor might be
AFFILIATION: 1Nagasaki Rosai Hospital, Sasebo, Japan, 2Nagasaki involved in the tourniquet pain resulting from continuous stimulation of
University School of Medicine, Nagasaki, Japan. C-fibers.
REFERENCES:
INTRODUCTION:The mechanisms of tourniquet pain are not well 1.Anesth Analg2001;92:1286-9
known. This study was designed to evaluate whether pre-administration 2.Anesth Analg 1994;79:787-91
of low-dose ketamine could attenuate tourniquet pain in healthy
volunteers.
METHODS:The subjects of the study were ten healthy
volunteers(males,22-50yrs). Tourniquet inflation was performed with
pressure of 400mmHg at the thigh and concluded when the pain rose to
a pre-determined level. Pain was assessed using a visual analog
scale(VAS,0-100mm) until reaching maximum pain or maximum time
of 60-min period. If the subjects recorded VAS100 before the end of 60-
min period, they were assigned the maximum value for the rest of the
time. Ketamine, 0.1mg/kg, or normal saline was given intravenously in
a double blind fashion before tourniquet inflation(T0). Each subject
recieved both of the test substances in a randomized order.
Measurements included VAS, tourniquet time(from inflation to
deflation), systolic blood pressure(SBP), and plasma concentrations of
catecholamines(CAs). VAS and SBP were measured just after touniquet
inflation(T1) and at 5-min intervals(T2-10), and plasma concentrations
of CAs were measured before tourniquet inflation and just before
tourniquet deflation. ANOVA and Student's t-test were used for
statistical comparison. Data were shown in mean±SD.
RESULTS: All subjects could not tolerate tourniquet pain more than 45
minutes. Low-dose ketamine significantly reduced VAS compared to
saline,i.e.,66.2±11.8 vs 90.0±10.3(P<0.0001) at T1, 59.6±23.8 vs
79.3±16.1(P<0.05) at T6 and 70.6±15.8 vs 86.7±15.5(P<0.05) at T7,
and significantly(P<0.01) prolonged tourniquet time(33.6±6.6 min vs
28.3±5.7 min). SBP(124.6±6.4 mmHg at T0) significantly increased at
T7(132.7±12.5 mmHg vs T0,P<0.05) and T8(143.3±5.1 mmHg vs
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AXILLARY BLOCK WITH NEWLY DEVELOPED PENTAGON needles: the anesthesiologist could feel the axillary sheath with the
POINTED NEEDLE Pentagon pointed needle much better than with the Quincke
pointed.(Table 1)(P<0.001).
AUTHORS: K. Mamiya, T. Sekikawa, K. Aizawa, K. Sengoku, O. STUDY 2. The maximum resistance was significantly higher in the
Takahata, H. Iwasaki Pentagon pointed needle(45.41±16.38, n=5) than in the Quincke
AFFILIATION: Asahikawa Medical College, Asahikawa, Japan. pointed (2.17±0.75,n=5) (P<0.005).
CONCLUSION: These results suggest that using the Pentagon pointed
INTRODUCTION: The Axillary Block is a common anesthetic needle will allow the anesthesiologist to sense more precisely the exact
procedure for patients undergoing operations on an upper extremity. penetration of the axillary sheath when performing the axillary block.
Because the Quncke pointed needle is so sharp, the anesthesiologist We conclude that this newly developed Pentagon pointed needle is
cannot easily sense the point of penetration through the axillary particularly useful and increases safty for the axillary block.
sheath.Therefore, obtaining the appropriate field of analgesia can be
difficult. table 1:Comparison Between Two Needles with the Sensation of Axillary Sheath
The present study was designed to investigate how sensitively the
anesthesiologist could feel the axillary sheath with the new Pentagon needle type exellent good fair none
pointed needle (Dr.Japan Co,Tokyo,Japan)compared with the Quincke Pentagon pointed (n=7) 6 1 0 0
pointed. We also measured the penetration resistance of the axillary Quincke pointed (n=7) 0 0 2 5
sheath using these two kinds of needles in human cadaver.
MATERIALS AND METHODS: STUDY 1.Seven patients aged 45 to
79 undergoing the elective orthopedic operations were informed
consented about our study described below. All of them were
premedicated. The induction of anesthesia was carried out with the
propofol and they were insulted the laryngeal mask or intubated the
tracheal tube. Subsequently, the anesthesiologist performed the axillary
block. In the first instance, we penetrated the axillary sheath with the
Quincke pointed needle, measured the sensation of resistance of the
sheath using the four-grade scale(1.exellent,2 good,3.fair, 4.none) then,
in the second instance, with the Pentagon pointed. After that we
completed the injection of local anesthetic using the Pentagon pointed
needle. Data were evaluated by ANOVA, followed by Mann-Whitney’s
U test. P<0.05 was considered as statistically significant.
STUDY 2. Using the axillary sheath from the cadaver, we measured the
maximum resistance(mmHg) to complete the penetration, 5 times with
each needle type. Data were evaluated by Student’s t-test. P<0.05 was
considered as statistically significant.
RESULT: STUDY 1. Axillery block was successful in all 7 patients
without any neurological complications. Comparison between two
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DOES PREEMPTIVE ANALGESIA REALLY WORK? A to each patient for breakthrough pain was recorded, and the number of
COMPARISON OF OXYCONTIN, ROFECOXIB AND patients requiring morphine treatment was documented in each group.
PLACEBO IN PATIENTS UNDERGOING ELECTIVE RESULTS: The average total dose of morphine required for each
LAPAROSCOPIC CHOLECYSTECTOMY patient was 2.8 mg, 4.8 mg and 3.4 mg in the Oxycontin, rofecoxib and
placebo groups respectively. However, using analysis of variance
AUTHORS: K. Chaudhuri1, J. Boone1, E. L. McGuire1, J. Rivera2, S. testing, no statistical difference was observed among the three groups (p
Chaudhuri1 > 0.05). With regards to incidence of breakthrough pain, 13/23 patients
AFFILIATION: 1Texas Tech University Health Science Center, El in Group 1, 7/25 in Group 2, and 10/23 patients in Group 3, did not
require any supplemental morphine in the PACU. Furthermore, there
Paso, TX, 2UT Austin and El Paso - Cooperative Pharmacy Program, El was no obvious difference in pain scores among the three groups;
Paso, TX. however, there appeared to be a trend for greater morphine requirement
INTRODUCTION: Recently, there has been renewed interest in the rofecoxib group.
regarding the role of preemptive analgesia with long acting oral DISCUSSION: This study raises some questions regarding the efficacy
medication in the management of postoperative pain (1, 2). The purpose of oral preemptive analgesia with Oxycontin (10 mg) or rofecoxib (50
of this study was to compare the postoperative analgesic effects of mg) in the management of postoperative pain following laparoscopic
Oxycontin, rofecoxib and placebo in patients undergoing outpatient cholecystectomy.
laparoscopic cholecystectomy. REFERENCES:
METHODS: Following approval from the Institutional Review Board, 1. Can J Anesth 41:98-101, 1994.
a randomized double blinded placebo controlled study was undertaken 2. Anesth Analg 94:55-59, 2002.
in ASA 1 and 2 patients. Group 1 (n=23) received 10 mg of Oxycontin,
Group 2 (n=25) received 50 mg of rofecoxib, and Group 3 (n=23)
received the placebo tablet. Exclusion criteria included patients less
than 18 years or more than 65 years of age, patients with history of
hypersensitivity to codeine, pregnancy, renal or hepatic disease,
substance abuse, patients who had received any pain medications within
24 hours before surgery, and conversion to open cholecystectomy. All
patients were administered their medications orally, approximately 60
minutes prior to surgical incision. Induction of general anesthesia was
accomplished with propofol (1.5-2 mg/kg), fentanyl (2 mcg/kg) and
cisatracurium (0.2 mg/kg) or rocuronium (0.6 mg/kg). Following
intubation of the trachea, general anesthesia was maintained with
O2:N2O (50:50) and isoflurane (0.6-1.2%), together with intermittent
boluses of fentanyl and muscle relaxant. Patients did not receive any
other analgesics during surgery, nor was any local anesthetic infiltrated
at the sites of surgical incisions at any time during the procedure. In the
postanesthesia care unit (PACU), pain and sedation levels were assessed
every half-hour until discharge. Total dosage of morphine administered
2003; 96; S-1–S-293 S-202
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A PROSPECTIVE, RANDOMIZED TRIAL OF THREE 3mcg/kg at induction and 1mcg/kg for breakthrough pain
PERIOPERATIVE ANESTHETIC TECHNIQUES IN PATIENTS intraoperatively. Postoperative pain was treated with an intravenous
UNDERGOING BOWEL RESECTION PCA infusion of morphine set to deliver no basal, 1mg demand with a
6-minute lockout. All patients postoperatively received ketorolac 15mg
AUTHORS: R. V. Miguel1, T. J. Yeatman2, J. E. Marcet3, A. Walker1 IV q6h RTC until tolerating clear liquids for 4 hours, and then rofecoxib
AFFILIATION: 1Anesthesiology / H. Lee Moffitt Cancer Center and 50mg PO qAM was begun. Patients were evaluated every 6 hours and
Research Institute / University of South Florida, Tampa, FL, 2Oncology examined for bowel sounds, passage of flatus, PO tolerance, time to
/ H. Lee Moffitt Cancer Center and Research Institute / University of first passage of stool and discharge. Categorical data were compared
with Pearson's chi-squared test. Continuous data were compared with
South Florida, Tampa, FL, 3Surgery / H. Lee Moffitt Cancer Center and an analysis of variance and Tukey's post hoc test.
Research Institute / University of South Florida, Tampa, FL. RESULTS: There were no intergroup differences in age, gender
INTRODUCTION: The principal factors preventing earlier discharge distribution, or postoperative pain intensity. Outcome data are
after bowel resection are ileus, pain, and postoperative nausea and summarized in the table (Data are presented as mean ± SD; *p < 0.05
vomiting. Opioids affect all of these; however, would the absence of vs. Opioid Anesthesia).
opioids alone improve postoperative patient condition and allow for a DISCUSSION: Our preliminary results demonstrate that excluding
more rapid recovery? The purpose of this study is to determine whether opioids from the perioperative analgesic regimen in patients undergoing
there are differences in return of bowel function and hospital stay in lower abdominal colonic surgery allows for a faster
patients who undergo lower abdominal bowel surgery when using return of bowel function with comparable pain relief. Factors other than
epidural local anesthetic regimens, with and without opioids. return of bowel function delay patients hospital discharge.
METHODS: ASA Class I-III patients aged 18-80 years of age
scheduled to undergo lower abdominal colon resection were studied. Epidural Anesthesia
Time to event (days) Opioid Anesthesia
All patients received 2mg midazolam and 30mg ketorolac IV wo/opioids w/opioids
preoperatively. All patients received propofol for induction (1.5-2.5mg/
kg) and maintenance of anesthesia titrated to a BIS of 40-60 and a Bowel Sounds (n) 1.0 ± 0.5 (9) 0.9 ± 0.4 (8) 1.0 ± 1.1 (8)
rocuronium infusion to maintain 1-twitch in a train-of-four. Patients in Flatus (n) 1.3 ± 0.7 (9)* 2.1 ± 0.6 (8) 4.2 ± 2.1 (6)
Group 1 received no opioids during the intraoperative and postoperative Bowel movement (n) 2.6 ± 1.4 (7)* 3.8 ± 0.9 (8) 5.6 ± 1.7 (5)
period until return of bowel function and their analgesia was provided
by 5ml 0.75% aliquots of ropivacaine intraoperatively. A continuous Ingestion of clear liquid (n) 2.7 ± 1.0 (6)* 2.5 ± 1.5 (6) 5.2 ± 2.5 (5)
epidural infusion of 0.2% ropivacaine postoperatively was started at Hospital discharge (n) 6.1 ± 2.7 (9) 6.0 ± 1.2 (8) 7.7 ± 2.4 (8)
6ml/h and titrated to patient response. Patients in Group 2 received the
same epidural management intraoperatively but also received 1mcg/kg
fentanyl with each ropivacaine aliquot. During the final 20 minutes of
operation, patients were given 0.1mg/kg morphine intravenously.
Postoperative pain was managed by ropivacaine 0.2% at 6ml/h and
breakthrough pain was treated with an intravenous PCA infusion of
morphine set to deliver no basal, 1mg demand with a 6-minute lockout.
Patients in Group 3 did not receive an epidural but received fentanyl
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PATIENTCONTROLLED INTRAVENUOUS ANALGESIA: DISCUSSION: Identical pain intensity and cumulative use of opiods in
MORPHINE VERSUS PIRITRAMIDE ml at all times indicate that the choosen doses of M and P were
equianalgesic. A ratio of 0.7 vs. 1.0 for P and M seems to be equivalent.
AUTHORS: A. Kopf, U. Aden, H. Gandert, T. Luck, C. Stein Therefore the primary endpoints nausea and sedation could be evaluated.
AFFILIATION: Pain Management Center, Benjamin Franklin The prejudices against M could not be confirmed. M had lesser emetic
Medical Center, Free University of Berlin, Berlin, Germany. and sedating effects than P. The specific pharmacokinetic profile (2) of P
could be responsable for the better subjective tolerance of M. It is
INTRODUCTION: Patientcontrolled intravenuous analgesia (PCIA) is concluded that M is superior to P. Therefore, it would appear reasonable
a common method of providing control for acute postoperative pain. A to replace P with M in clinical practice for PCIA.
number of different opioids have been tested and found to be useful REFERENCES:
alternatives (1). In some European countries the strong u-agonist (1) Pain 1999; 80(3): 545-53.
piritramide (P) is the standard opioid for PCIA, in anglo-saxon countries (2) Anesthesiology 1999; 90(1): 7-15.
mostly morphine (M). No controlled studies have compared P and M.
Economical and practical considerations would favor M. From the
available literature we hypothesed that P has less sedating and more
nauseating effects than M.
METHODS: 42 patients (ASA I and II only) were studied after IRB
approval and informed patient consent. 20 patients in each group were
necessary to detect a clinically relevant difference of more than 20% for
nausea and sedation. Patients were randomly assigned double-blinded
into two groups (M and P). Only patients after elective "open" abdominal
surgery were included. Patients with a history of motion sickness or
postoperative nausea were excluded. All patients received identical
anesthesia with fentanyl 2 ug/kg*hr and isoflurane as needed. Patients did
not receive antiemetic prophylaxis. After arrival in the recovery room
patients randomly received a PCA-pump (Graseby 9300) which delivers
on demand a 4 ml bolus with either 1.5 mg M or 2 mg P with 10 min
lock-out and without basic infusion rate. With NAS <= 3 patients were
discharged from the recovery room. Pain, sedation and nausea were
evaluated by a blinded observer at 6 times within the next 48 hours.
Sedation and nausea were evaluated with categorial and analog scales.
RESULTS: Demographic data and type of surgery were not significantly
different between both groups. Quality of analgesia and consumption of
M and P (in ml) were identical at all times. On postoperative day 1 the
incidence of nausea and "severe sedation" were higher (p<0.05) with P.
Results did not differ for analog and categorical scales.
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THE EFFECT OF ACUTE POSTOPERATIVE PAIN ON RANGE by POD 2 and to 2.2 ± 1.7 for POD 3-5 (discharge). Examination of the
OF MOTION AT TIME OF DISCHARGE AFTER TOTAL KNEE correlation matrix indicates that VAS is negatively related to ROM at
ARTHROPLASTY discharge, with the 4 hours postoperative VAS most strongly correlated.
A linear regression was used to evaluate the predictive power of VAS
AUTHORS: A. Buvanendran, M. Moric, D. Elmofty, J. S. Kroin, K. J. on both active and passive flexion. Linear regressions on both active
Tuman and passive flexion produce r2 values of 0.52 and 0.59 respectively
AFFILIATION: Dept. of Anesthesiology, Rush Medical College, (figure) and significant regression slope coefficients (P<0.0001). High
Chicago, IL. scores on VAS, predict less flexion for both active and passive
movements. Correspondingly, low VAS scores lead to higher degrees of
INTRODUCTION: Improvement in surgical techniques, favorable flexion at time of discharge.
outcomes and patient satisfaction after total knee arthroplasty (TKA) DISCUSSION: This prospective study demonstrates that lower pain
are closely associated with the range of motion (ROM) of the operated scores on the first postoperative day is associated with an increase in
knee. About 60% of patients undergoing TKA experience severe acute both active and passive flexion on postoperative day 4 at the time of
postoperative pain, which hinders rehabilitation (1). This prospective discharge. Effective pain management immediately after TKA appears
study was conducted to determine if acute postoperative pain after TKA to be associated with improved functionality at the time of hospital
predicts subsequent ROM of the knee. discharge.
METHODS: Following IRB approval and informed consent, 49 REFERENCES:
patients scheduled for primary TKA were studied. All patients had a (1) Bull Hosp Joint Dis 1993; 53: 35-40
combined spinal (11.25 mg hyperbaric bupivacaine and 25 g fentanyl) -
epidural anesthetic technique for the surgery. Patients had a
standardized surgical technique of tourniquet and fixation of the bi-
condylar components with methylmethacrylate. In the recovery room an
epidural infusion of bupivacaine 1 mg/ml and fentanyl 10 g/ml at 6 ml/
hr with a PCA mode of 1 ml every 15 minutes was commenced and
titrated to achieve visual analog scale (VAS) 3-5 for 2 days.
Immediately postoperatively VAS was measured every 4 hours and
from postoperative day (POD) 1 it was measured daily till discharge
(mean 4.7 days). On POD 2 patients were commenced on oral
hydrocodone (4-6 tablets/day) for pain relief. All patients received
physical therapy and ROM parameters were monitored. The active and
passive flexion of the operated knee was measured goniometrically.
Demographic data are expressed as mean ± SD. Pearson correlation
coefficient was utilized to examine the relationship between VAS and
ROM.
RESULTS: The mean age of the study group was 61.9 ± 9.5 years with
a male: female ratio of 13: 36 and a mean weight of 202.1 ± 38.4 lbs.
The mean VAS was 4.0 ± 3.1 on POD 1, which decreased to 3.0 ± 1.8
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FASCIA ILIACA BLOCKS FOR POST-OPERATIVE DISCUSSION: The ease of performing fascia iliaca blocks, the high
ANALGESIA IN TOTAL KNEE ARTHROPLASTY PATIENTS degree of success and satisfaction, and the lack of complications make
them useful adjuncts in managing the postoperative pain in TKA patients.
AUTHORS: S. L. Blum, D. Wu, A. Schroeder, K. Quarnstrom, W. Quadriceps weakness may be potentially beneficial since it can prevent
Goldstein spasm, a common cause of failure to progress in PT. We recommend the
AFFILIATION: Depts. of Anesthesiology and Orthopedics, Rush incorporation of FIBs into the traditional acute postoperative pain
North Shore Medical Center, Skokie, IL. management for TKA This approach may be particularly useful for
patients requiring regional analgesia in the face of anticoagulation.
INTRODUCTION: The increasing utilization of new anti-coagulant
drugs and early utilization of warfarin following orthopedic joint
replacement has prompted anesthesiologists to adapt new strategies for
the treatment of postoperative pain. Pain management in total knee
arthroplasty (TKA) patients is challenging and often requires approaches
beyond IV patient controlled analgesia, including regional blocks. We
report the clinical results of using fascia iliaca blocks (FIB) in comparison
with epidural analgesia after TKA.
METHODS: In our institution TKAs are typically performed under
epidural/general anesthesia. We evaluated the clinical course of 406
consecutive patients undergoing TKA. Epidural analgesia was
discontinued in the evening of postoperative day 1. All patients with pain
scores >5 were offered FIBs. FIB is easily performed at the bedside with a
22g B bevel needle inserted 1cm below the junction of the lateral 1/3 and
medial 2/3 of the inguinal ligament and anesthetizes the femoral and
lateral femoral cutaneous nerves. The needle is inserted perpendicularly
until two “pops” are felt (fascia lata and fascia iliaca). After negative
aspiration, 20ml 0.25% bupivacaine with 200 mcgms epinephrine and
100 mcgms clonidine is injected. Pain scores (VAS) were compared
before and after FIB and to VAS with epidural analgesia using the Mann-
Whitney nonparametric test.
RESULTS: The first attempt success rate for FIB was 82%. All repeated
attempts had 100% success. There were no complications with the 96
FIBs and 98% of these patients were satisfied. Pain scores 1 hr after FIB
were reduced by an average of 3.86 ± 2.22 and similar to VAS in patients
with epidural analgesia (3.04 ± 1.96 vs 2.68 ± 2.8 respectively).
Quadriceps weakness was noted during the morning physical therapy
(PT) visit but did not impede the patient’s ability to accomplish the given
tasks. By the afternoon PT visit no weakness was noted.
2003; 96; S-1–S-293 S-206
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EFFECT OF LOCAL ANESTHETIC WOUND REFERENCES:
ADMINISTRATION ON RECOVERY AFTER MAJOR 1) Rawal N, Axelsson K, Hylander J, et al. Postoperative patient-
ORTHOPEDIC SURGERY PROCEDURES controlled local anesthetic adminstration at home. Anesth Analg 1998;
86:86-9.
AUTHORS: M. Coloma, A. Recart, P. F. White, J. D. Griffin, F. 2) Fredman B, Shapiro A, Zohar E, et al. The analgesic efficacy of
Gottschalk, K. Christensen patient-controlled ropivacaine instillation after cesarean delivery.
AFFILIATION: University of Texas Southwestern Medical Center, Anesth Analg 2000; 91: 1436-40.
Dallas, TX. 3) Fredman B, Zohar E, Tarabykin A, et al. Bupivacaine wound
instillation via an electronic patient-controlled analgesia device and a
INTRODUCTION: Controversy exists regarding the analgesic double catheter system does not decrease postoperative pain or opioid
efficacy of local anesthetic wound instillation via either patient- requirement after major abdominal surgery. Anesth Analg 2001; 92:
controlled (1,2), or continuous infusion (3) delivery systems. The 189-93.
objetive of this study was to assess the effect of a local anesthetic
infusion in preventing pain after major orthopedic procedures. Control Bupi 0.25% Bupi 0.5%
METHODS: 50 patients undergoing unilateral total knee of hip n=14 n= 18 n= 18
replacement surgery were enrolled in this randomized, prospective, Age (yr) 56±14 58±13 63±10
double-blinded, placebo-controlled study. Upon completion of surgery,
one multihole 20-ga. epidural catheter was placed under direct vision Weight (kg) 89±20 90±2 89±26
above the fascial layer prior to wound closure. Postoperatively, an On- Knee/hip surgery (n) 6/8 11/7 7/11
Q™ infusion pump system (I-Flow Corporation) containing 270 ml of General/Spinal Anesthesia (n) 8/6 8/10 9/9
bupivacaine 0.25% (Bupi 0.25%), bupivacaine 0.5% (Bupi 0.5%), or
saline solution (Control), was connected to the irrigating catheter, and Intraoperative morphine (mg) 1.4±3 2.0±4 1.8±4
the study medication was infused at a rate of 5 ml/hr. Patients' need for Intraoperative fentanyl (µg) 136±104 140±200 117±188
"rescue" pain medications, total dose of opioids analgesics (mg), pain PCA morphine at 72 h (mg) 43±25 53±29 30±16*
scores (0=none and 10= highest) and satisfaction with pain
management (0-100) were recorded at specific intervals for up to 1 Patient satisfaction at 72 h/7 d (0-
76±17/79±20 79±14/79±13 84±19/83±25
week after surgery. Data was analyzed using ANOVA and 2 tests. P 100)
values <0.05 were considered significant (*). Pain score at 7 d (0-10) 4±2 4±2 3±3
RESULTS: Demographic data were comparable among the three
treatment groups. The total dose of PCA morphine administered during
the first 72 postoperative hours was significantly reduced in the 0.5 (vs.
0.25%) bupivacaine group (30±16 vs. 53 ±29 mg, respectively).
However, pain scores and patients' satisfaction were not significantly
different between the three groups up to 1 week after surgery.
CONCLUSIONS: Local anesthetic instillation at the surgical site
failed to significantly improve pain control or facilitate recovery after
major joint replacement surgery.
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INTRATHECAL CLONIDINE DID NOT IMPROVE REFERENCES:
POSTOPERATIVE PAIN MANAGEMENT AFTER COMPLEX Urban MK et al. Spine. 2002;27:535-537. Eisenach JC et al. Anesth
SPINE SURGERY. Analg. 1998;87:591-6.
AUTHORS: M. K. Urban, J. Beckman, B. Wukovits, W. Kelsey Data for the first postoperative 24 hours.
AFFILIATION: Hospital for Special Surgery, New York, NY. Control Group Clonidine Group
INTRODUCTION: Patients who undergo complex spine surgery have Mean VAS 2.3±2.0 3.0±1.5
significant postoperative pain which is often difficult to manage. Postoperative LR (cc) 2600±600 3400±800
Treatment with large doses of narcotics often results in a high incidence
of side-effects. Clonidine, an 2-selective agonist, has been used Dilaudid (mg) 26±18 26±22
perioperatively both as a narcotic sparing agent and for the reduction in Hypotensive patients (n)* 2 3
the hemodynamic responses to stressful stimuli. We previously Treated vomiting (n) 1 2
demonstrated that intrathecal morphine improved postoperative pain
management in these patients. In this pilot study we evaluated the Naloxone treated (n) 0 2
addition of intrathecal clonidine. *Hypotension: SBP<100mmHg, treated.
METHODS: Ten patients with spinal deformities for elective anterior
then posterior spinal fusions with instrumentation were randomly
assigned to receive 15mcg/kg intrathecal morphine with (clonidine
group) or without (control group) 1 mcg/kg clonidine (Duraclon® )
through a 25G spinal needle prior to posterior instrumentation. All
patients received the same 70% nitrous oxide, 0.3% isoflurane and 1-2
mcg/kg/h fentanyl general anesthetic. Postoperatively, pain was treated
to a VAS (visual analog pain scale, 1-10) of 2-3 with i.v. dilaudid PCA
and in the clonidine group a 0.1mg clonidine (Catapress® ) patch.
RESULTS: There was no statistically significant difference between
groups in patient demographics, the length of surgery, number of spinal
segments fused or estimated blood loss (not shown). Both groups
required almost identical quantities of i.v. dilaudid to maintain a VAS
score of 2-3. The clonidine group received more i.v. crystalloid and two
patients compared to none in the control group required naloxone for
respiratory depression.
CONCLUSION: In this pilot study, there was no advantage to the
addition of clonidine to the perioperative pain regimen. Furthermore,
due its sedative and sympathetic effects, the addition of clonidine may
result in increased fluid requirements and respiratory depression.
S-208 2003; 96; S-1–S-293
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ANALGESIC EFFECT OF A SINGLE 7.5 MG DOSE OF IV morphine group were rescued 23± 15 min (range 5-55 min) after and
MORPHINE FOLLOWING TOTAL ABDOMINAL those receiving placebo 18± 14 min (range 3-82 min) after the study
HYSTERECTOMY: COMPARISON TO PLACEBO drug administration. There was no significant difference in pain
intensity between morphine and placebo at baseline, 2, 5, 10, or 15
AUTHORS: R. Domsky, M. E. Goldberg, T. Rocereto, J. Aikins, B. minutes after the study drug administration. However, at 2 min the
Khaleghi, G. E. Larijani patients receiving morphine stated greater pain relief than those
AFFILIATION: Cooper Health System. UMDNJ, Camden, NJ. receiving placebo; these patients reported no significantly greater pain
relief at any other time. Overall patients receiving morphine were more
INTRODUCTION: Patients undergoing total abdominal hysterectomy satisfied with pain relief than. The investigator’s satisfaction with pain
(TAH) often complain of moderate to severe pain in the immediate relief was the same in both groups.
postoperative period. Morphine sulfate is a commonly used analgesic in DISCUSSION: A single initial high bolus dose of morphine (7.5 mg,
this patient population. The initial dose of morphine is often IV) does not appear to significantly reduce the intensity of perceived
institutionally fixed but usually ranges between 1-3 mg. The aim of this pain in TAH patients. Patients, however, gave a significantly higher
study was to evaluate the analgesic effect of a relatively large initial analgesic score to morphine. Dose titration to effect should replace
dose of morphine (7.5 mg IV) as compared to placebo in patients fixed dose administration for better pain control.
following TAH.
METHODS: Informed consents were obtained from 61 female patients
with a mean age of 47 (9) years scheduled to undergo TAH under
general anesthesia in this IRB approved study. Anesthetic management
of the patients was standardized and consisted of fentanyl, propofol,
nitrous oxide, muscle relaxants, and isoflurane. Patients with a
moderate or a severe degree of pain in the PACU were randomly
assigned to receive either a 7.5 mg bolus dose of morphine or placebo.
Patients were encouraged to wait up to 15 min but had access to rescue
medication at any time. Following the study administration subjects
were frequently asked to rate their pain intensity (none, mild, moderate,
and severe) as well as any pain relief (pain is worse, no pain relief, mild
pain relief, moderate pain relief, or complete pain relief). Immediately
before the first dose of rescue medication both subject and the
investigator independently assessed their overall satisfaction with the
analgesic efficacy of the study drug using a 5-point scale (poor, fair,
good, very good, or excellent). Data was analyzed using 95%
Confidence Interval and is reported as mean ± SD.
RESULTS: Twenty-five patients received morphine and 31 patients
received placebo. There were no significant differences in any of the
demographic data between the two groups. There was no significant
difference in time to rescue between the groups. Patients in the
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ANALGESIC EFFECT OF A SINGLE 7.5 MG DOSE OF IV RESULTS: Twelve patients received morphine and 15 received
MORPHINE FOR THE TREATMENT OF PAIN AFTER placebo. There were no significant differences in any of the
RADICAL PROSTATECTOMY: COMPARISON TO PLACEBO demographic data between the two groups. Patients in the morphine
group were rescued 15± 9 (range 5-32 mi) min after and those receiving
AUTHORS: B. Khaleghi, M. Goldberg, D. Warshal, R. Hirsh, I. Gratz, placebo 16± 13 min (range 5-51 min) after the study drug
G. E. Larijani administration. Pain intensity was significantly lower in the morphine
AFFILIATION: Cooper Health System. UMDNJ, Camden, NJ. group at 5 min. Patients receiving morphine, however, stated a greater
amount of pain relief at 2, 5, 10, and 15 min after its administration.
INTRODUCTION: Patients undergoing radical prostatectomy often Neither the patients nor the investigators gave a significantly higher
complain of moderate to severe pain in the immediate postoperative score for morphine effectiveness as an analgesic agent.
period. Morphine sulfate is a commonly used analgesic in this patient DISCUSSION: A single 7.5 mg IV bolus dose of morphine does not
population. The initial dose of morphine is often institutionally fixed appear to provide adequate reduction in the perceived pain intensity
but usually ranges between 1-3 mg. The aim of this study was to despite patients’ experience of significantly more relief. Neither the
evaluate the analgesic effect of a relatively large initial dose of investigators, nor the patients, gave a higher score with respect to
morphine (7.5 mg IV) as compared to placebo in patients following analgesic efficacy in the morphine group. Dose titration to effect should
prostatectomy. replace fixed dose administration for better pain control.
METHODS: Informed consents were obtained from 27 male patients
with a mean age of 56 (6) years scheduled to undergo radical
prostatectomy under general anesthesia to participate in this IRB
approved study. Anesthetic management of the patients was
standardized and consisted of fentanyl, Propofol, nitrous oxide, muscle
relaxants, and Isoflurane. Patients were frequently questioned in the
PACU about the degree of pain using a 4-point verbal scale (none, mild,
moderate, and severe). Patients with a moderate or severe pain were
randomly assigned to receive either a 7.5 mg bolus of morphine or
placebo. Following the study drug administration subjects were
frequently asked to rate their pain intensity using the above 4-point
scale as well as any degree of pain relief (pain is worse, no pain relief,
mild pain relief, moderate pain relief, or complete pain relief). Patients
were encouraged to wait up to 15 min but had access to rescue
medication at any time. Immediately prior to the first dose of rescue
medication both the subject and the investigator independently assessed
their overall satisfaction with the analgesic efficacy of the study drug
using a 5-point scale (poor, fair, good, very good, or excellent). Data
was analyzed using 95% Confidence Interval and is reported as mean ±
SD.
2003; 96; S-1–S-293 S-210
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CARDIOVASCULAR AND RESPIRATORY EFFECTS OF A approximately 9% in patients receiving morphine; those receiving
SINGLE 7.5 MG DOSE OF IV MORPHINE COMPARED TO placebo had no significant drop on diastolic blood pressure at this time
PLACEBO IN POSTOPERATIVE PATIENTS point.
CONCLUSIONS: A single initial high bolus dose of morphine (7.5
AUTHORS: I. Gratz, J. Cantillo, E. Deal, M. Goldberg, B. Khaleghi, mg, IV) does not appear to cause clinically significant alterations in
G. E. Larijani cardiovascular or respiratory parameters. By giving a larger initial dose
AFFILIATION: Cooper Health System. UMDNJ, Camden, NJ. of morphine prompt control of pain can be achieved with minimum
alterations in cardiovascular or respiratory parameters. Dose titration to
INTRODUCTION: The initial dose of morphine for the treatment of effect using higher doses of morphine should replace fixed dose
postoperative pain is often institutionally fixed. To prevent a sudden administration for better pain control.
change in cardio-vascular status initial doses in the range of 1-3 mg is
often given. Higher doses are thought to significantly change
hemodynamic stability or result in significant respiratory depression. In
this study we report the hemodynamic and respiratory data following an
initial high dose morphine (7.5 mg IV) in postoperative patients
complaining of moderate to severe pain.
METHODS: Informed consents were obtained from 108 patients (80
females, 28 males) scheduled for lower abdominal surgeries to
participate in this IRB approved study. Anesthetic management of the
patients was standardized and consisted of fentanyl, propofol, nitrous
oxide, muscle relaxants, and isoflurane. Patients with a moderate or a
severe degree of pain in the PACU were randomly assigned to receive
either a 7.5 mg bolus dose of morphine or an equal volume of placebo.
All patients were on supplemental oxygen supplied by a nasal cannula
with flows of 2 L/min. Vital signs were recorded at baseline and at 1, 2,
5, 7, 10, and 15 minutes after the study drug administration. Data was
analyzed using 95% Confidence Interval and unpaired student t-test and
is reported as mean ± SD.
RESULTS: Fifty patients (37 F, 13 M) received morphine and 58
patients (43 F, 15 M) received placebo. There were no significant
differences in any baseline hemodynamic data between the two groups.
The administration of morphine, or placebo, had no significant effect on
systolic blood pressure, hear rate, oxygen saturation, or respiratory rate
at any time during the time course of the study. Diastolic blood pressure
was significantly lower in patients receiving morphine only at 5 min
data collection time (68.3 ±15.3 mmHg vs. 74.2 ±12.4 mmHg, P<0.05).
The mean percent drop in diastolic blood pressure at 5 min was
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PAIN MANAGEMENT FOR A PREGNANT PATIENT WITH weakness, or infection. The maximal serum concentration was
UTERUS LEIOMYOMA - A LONG-TERM EPIDURAL 0.6microgram/ml. No analgesics were required after 34th week of
INFUSION OF ROPIVACAINE gestation, and elective cesarean delivery was carried out uneventfully at
38th week of gestation. Apgar score for one and 5 minutes was 8 and 10
AUTHORS: A. Ishikawa, Y. Kobayashi, Y. Aoyama points, respectively and neonatal umbilical cord blood pH value was
AFFILIATION: National Hospital Tokyo Medical Center, Tokyo, 7.363. The neurobehavioral testing on 4th postnatal day represented no
Japan. abnormality.
CONCLUSION: There are the possible risks of delayed effects upon
INTRODUCTION: Abdominal pain in a pregnant patient with uterus prenatal exposure to a given drug even if the organogenetic period has
leiomyoma often causes the premature labour. Therefore, a safe and passed. In our case, however, maternal serum concentration of
effective pain management is required. IV or oral administration of ropivacaine was extremely low, and perinatal assessment revealed no
opioids and/or NSAIDs might fail to achieve a complete pain relief and abnormality despite a long-term exposure. These findings support a
not be able to prevent the premature labour despite adverse effects. In long-term epidural analgesia in the case of a pregnant patient. An
this report, a pregnant patient with leiomyoma was successfully appropriately placed chronic epidural catheter and a titrated continuous
managed by continuous epidural infusion of plain ropivacaine. This is infusion of ropivacaine provided adequate and safe analgesia for
the first report of successful treatment of a pregnant patient with a long- leiomyoma-associated abdominal pain and certainly improved quality
term epidural analgesia. In this case, the effectiveness and the safety of of life in a pregnant patient.
this method were examined by measuring the maternal serum
ropivacaine concentration, and inspecting the neurobehavioral testing.
METHODS AND RESULTS: A 32-year-old primigravida presented
with lower abdominal pain at 25th week of gestation. On admission,
conservative treatment with pentazocine and tocolytics was started but
failed. Then, after informed consent had been obtained, continuous
lumbar epidural infusion of ropivacaine at fixed rate of 5 mL/h was
started. The infusion concentration was decreased by 0.05% according
to the clinical symptom and visual analog scales (VAS) for pain during
rest and movement. Maternal blood samples were collected at each
infusion concentration and serum ropivacaine concentration was
measured by the gas chromatography. Perinatal outcomes assessed were
neonatal umbilical cord blood pH value and Apgar score. In addition,
the newborn was evaluated by using the Brazelton and NACS
neurobehavioral testing.Ropivacaine infusion was continued from 27th
to 34th week of gestation, and infusion concentration was decreased
gradually from 0.2%, and the final concentration was 0.05%.
Throughout the intervention, the patient was allowed to continue to
perform daily activities with minimal discomfort. No complications
occurred such as local anesthetic toxicity, hypotension, motor
S-212 2003; 96; S-1–S-293
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RELIEF OF UTERINE ARTERY ENBOLIZATION PAIN BY in the VAS scores among the three R groups. The addition of droperidol
PATIENT CONTROLLED EPIDURAL ANALGESIA WITH significantly decreased the incidence of nausea/vomiting in group R-2
DIFFERENT MIXTURES and R-3 than R-1 and C with R-3 showing more sedation in 25% of the
patients. Vital signs were stable and no patient had respiratory
AUTHORS: S. She1, X. Xu1, M. S. Mok2, L. Xu1, C. Chen1, C. Liu1 depression in all 4 groups.
AFFILIATION: 1The First People's Hospital of Guangzhou, DISCUSSION: Our study showed that PCEA with ropivacaine and
Guangzhou, China, 2University of Southern California, Los Angeles, morphine provided effective and safe analgesia to patients with UAE
CA. pain and the addition of droperidol to the epidural drug reduced the
adverse effect of nausea/vomiting.
INTRODUCTION: Uterine Artery Embolization (UAE) is a
nonsurgical treatment for uterine tumor that is gaining increasing
acceptance. This procedure, however, is associated with considerable
amount of postoperative abdominal cramp pain. The usual pain control
is provided by the use of NSAID ( non-steroidal anti-inflammatory drug
) and parenteral opioid which in our experience frequently did not
provide satisfactory pain relief. The present study was undertaken to
evaluate the efficacy of patient controlled epidural analgesia
(PCEA)with three different anaglesic mixtures in the relief of post UAE
pain.
METHODS: After apporval from the Hospital Research Committee
and informed consents eighty patients who were scheduled for UAE
were randomly allocated into 4 equal groups: Group C (n=20) received
nimesulide 100 mg PO at 1 hour before the procedure and meperdine 1
mg/kg IM q4h prn after the procedure; Group R-1 (n=20) received
PCEA with a mixture of ropivacaine 0.2% + morphine 0.004%; Group
R-2 (n=20) received PCEA with a mixture of ropivacaine
0.2%+morphine 0.004%+droperidol 0.005%; Group R-3 (n=20)
received PCEA with a mixture of ropivacaine 0.2% + morphine
0.004%+droperidol 0.01%. All R groups had PCEA setting with
loading dose of 6 ml +continuous infusion 2 ml + bolus 2 ml at lockout
interval 10 min. VAS, Bruggman comfort score, Ramsay sedation score,
sensory and motor block, vital signs and adverse effects were assessed
for 48 hours.
RESULTS: Abdominal crampy pain was reported in 90% of the
patients in Group C but in none of the patients in all the R groups and
VAS were significantly higher in the C group than the R groups. Dose
of ropivaciane and morphine were similar with no significant difference
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COMPARING QUALITY OF LIFE IN PATIENTS WITH General Health (p<0.01). For the TOPS domains, the cancer pain group
CANCER-RELATED PAIN AND CHRONIC NONMALIGNANT reported greater Health Care Satisfaction (p<0.01) and less Total Pain
PAIN USING THE TREATMENT OUTCOMES IN PAIN Experience (p<0.05). However, they experienced more Work
SURVEY (TOPS) Limitations (p<0.05) and reported poorer perceptions in Solicitous
Response (p<0.001), which is a measure of the extent to which a spouse
AUTHORS: R. C. Polomano1, F. K. Orkin1, V. Gordin1, H. A. or significant other assumes role functions. The mean score for
Harvey1, A. J. Mannes2, D. B. Carr3 Perceived Family, a measure of the ability to perform family and social
AFFILIATION: 1Penn State College of Medicine, Hershey, PA, roles, was significantly better for cancer subjects (p<0.05).
2 Interestingly, the CNMP group indicated much greater Pain Symptoms
National Institutes of Health, Bethesda, PA, 3Tufts New England (p<0.001).
Medical Center, Boston, MA. DISCUSSION: We conclude that the TOPS may have important
INTRODUCTION: The Treatment Outcomes in Pain Survey (TOPS) contributions to the measurement of quality of life and treatment
is a comprehensive multidimensional tool developed by investigators at outcomes for persons with cancer-related pain. However, more studies
New England Medical Center, which measures physical and are needed to establish its validity and sensitivity for evaluating
psychosocial outcomes in outpatients with chronic nonmalignant pain physical and psychosocial dimensions of the cancer pain experience and
to refine the instrument to reduce the item burden to persons with
(CNMP).1,2 The TOPS is comprised of 8 subscales derived from the advanced cancer.
Medical Outcomes Study SF-36 Health Survey and 14 TOPS domains. REFERENCES:
To date, no published reports have documented use of the TOPS with 1
cancer-related pain. Therefore, we administered the survey to patients Rogers WH, et al. Pain Medicine 2001;1:55-67.
2
with cancer-related pain from advanced disease and compared their Rogers WH, et al. Pain Medicine 2001;1:44-54.
results to those of CNMP patients.
METHODS: Fifty-two subjects with advanced cancer reporting
average pain levels of >3 (0-10 Numeric Rating Scale) were recruited
from a hematology-oncology outpatient clinic and asked to complete
the TOPS. Scores were computed and compared to those of 94 CNMP
subjects who were new referrals to our Pain Management Clinic.
RESULTS: Psychometric properties of the TOPS were evaluated.
Internal consistency reliability (Cronbach's alpha) was calculated for
each of the 8 SF-36 subscales separately for both groups. All SF-36
subscales had coefficients of 0.70 or above and were remarkably similar
for most subscales, with differences between groups no greater than
0.11. Social Functioning was the lowest subscale for the cancer group,
0.70. The TOPS domains also demonstrated acceptable reliability for
both groups, except for Passive Coping which was 0.62 for the cancer
group and 0.77 for CNMP subjects. Scores from the SF-36 subscales
and TOPS domains were compared using Student's t-tests. Subjects with
cancer-related pain indicated less Body Pain (p<0.001), but poorer
2003; 96; S-1–S-293 S-214
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SYMPTOMATIC TREATMENT OF CHRONIC LOW BACK group. The only adverse reaction observed was skin irritation and minor
PAIN: DETERMINATION OF OPTIMAL SIGNAL blistering on one patient at the pain site electrode (n=1).
FREQUENCY AND PRELIMINARY EFFICACY OF A
TARGETED NON-INVASIVE ELECTRONIC PAIN CONTROL Feed
Beat Freq. VAS Rating VAS Rating VAS Rating VAS Rating
DEVICE Freq. n
(Hz) Baseline @ 20 min @ 30 min @ 50 min
(kHz)
AUTHORS: S. Panchal, S. Diwan, R. F. Eliazo, H. C. Hemmings 8 122 3 4.9+0.8 2.5+1.6 2.6+2.2 1.7+0.8
AFFILIATION: Weill Cornell Medical College, New York, NY.
13.33 122 8 6.7+1.5 4.3+3.0 2.8+1.7** 2.6+2.2**
INTRODUCTION: The Biowave System (Biowave Corporation, 26.8 122 5 5.7+0.6 2.6+0.8** 1.6+1.3** 2.0+2.2**
Norwalk, CT) introduces two premixed high frequency wave forms
(feed signals) through an electrode placed on the skin opposite the pain 8 90 7 5.3+1.0 2.3+2.1* 1.9+1.1** 3.3+2.5
site (feed electrode). The electric field contains a low frequency 8 122 3 5.0+1.3 1.6+0.7* 2.6+1.6 0.9+0.4*
component (beat frequency) equal to the difference between the feed
signals. The feed signals pass through the body to a second electrode at 8 150 3 5.9+1.8 3.6+2.7 1.8+2.5 0.9+1.1
the treatment site (pain site electrode). The feed signals mix, yielding an *p<0.05, **p<0.01 vs. baseline by ANOVA with Dunnett's post-hoc
electric field equivalent to the beat frequency component, which is test.
believed to interrupt transmission of pain impulses by preventing action DISCUSSION: At a beat frequency of 122 Hz, all 3 feed frequencies
potential propagation along pain fibers. This technology is being tested produced comparable analgesia as evidenced by >50% reductions
explored as a novel therapy for treating chronic, acute or post-surgical in VAS at the 3 time points tested. Variations in beat frequency at a feed
pain. frequency of 8 kHz showed significant reductions for 90 and 122 Hz.
METHODS: Volunteers consented to undergo 3 treatment sessions in Analgesia persisted for at least 30 min after the treatments. Further
either of 2 phases with varying beat and feed frequencies separated by studies are warranted to confirm the efficacy and safety of the system,
at least 24 hours. Criteria for inclusion: age 18-60, low back pain as well as the duration of analgesia. The data suggest that the Biowave
(below T12) for >3 months without radiation, and Visual Analog Scale System is effective in the symptomatic treatment of chronic low back
(VAS) pain score of >40 at screening. Exclusion criteria were pain.
pregnancy, presence of a pacemaker or other implantable devices, Supported by a grant from Biowave Corporation.
cardiac arrhythmias, epilepsy, low back surgery, alcohol or drug abuse,
or significant medical or psychological conditions. Subjects were
connected to the Biowave device by application of a large hydrogel feed
electrode (12.7 cm x 20.3 cm) to the abdomen and a smaller pain site
electrode (5.1 cm diameter) to the lower back over the source of the
pain. Subjects increased the power output of the device until tingling
was felt; treatment continued for 20 min. Patients completed VAS pain
assessments at baseline, after 20 min of treatment, and at 10 and 30 min
after the device was turned off.
RESULTS: 29 patients were enrolled; 3 subjects completed each
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PAMIDRONATE PRODUCES PAIN RELIEF FOR CHRONIC RESULTS: After the first month 80% of patients had a clinical relevant
BACK PAIN IN GLUCOCORTICOID-INDUCED reduction (more than 20%) of pain intensity score measured by VAS.
OSTEOPOROSIS Three months later, in 60% of patients the pain score felt to 50%. Only
twelve patients were treated with infusions during six months and their
AUTHORS: R. Gonzalez, E. Cano, J. Caballero, F. Garcia pain was nule or small. Every patient reduced analgesics consumption
AFFILIATION: Hospital Clinico San Cecilio, Granada, Spain. after three month of treatment and this reduction was higher after six
months of infusions. None patients have been treated during one year, at
INTRODUCTION: Pamidronate is an orally and intravenously active this moment, to carry out the second densitometry. We are planning to
amino-substituted bisphosphonate which produces potent and specific do it in the next months in order to determine if the pain relief is
inhibition of bone resorption. Clinical trials indicate that pamidronate is accompanied with an improvement of mineral bone density.
effective in a variety of conditions characterised by pathologically DISCUSSION: Intravenous pamidronate seems to be a valuable
enhanced bone turn-over, including Paget’s disease, hypercalcemia of treatment for chronic back pain due to glucocorticoid induced
malignancy, osteolytic bone metastasis, steroid-induced osteoporosis osteporosis.
and idiopatic osteoporosis. We carried out a prospective study to assess
whether intravenous pamidronate reduces the pain produced by
glucocorticoid-induced osteoporosis. The primary purpose of the study
was to determine the pain relief once a month after one year of
treatment with pamidronate injected monthly. A secondary endpoint
was to determine whether any differences in bone mineral density
appeared after one year of the treatment.
METHODS: Twenty-two patients with a long-term glucocorticoid
therapy (more than one year) and at least 10 mg daily of prednisona
were studied. All of them had moderate or severe back pain (VAS >6)
due to osteoporosis. After informed consent was obtained a blood
sample was taken to analyse Ca, Phosphoro, hemograma, liver function
(AST and ALT) and renal function (urea and creatinine). A bone hip
and lumbar vertebral densitometry was done at the beginning of the
study and after one year of the treatment in order to determine
differences in bone mineral density. Sixty milligrams of pamidronate
was administered intravenously once a week for one month followed by
an infusion of sixty milligrams once a month during one year.
Simultaneously patients were treated with 800 mg of calcium carbonate
per day. We assesed monthly pain by VAS, pain relief, analgesic
consumption and number of dreams hours. We also assesed any side
effects. Subsequent blood samples were taken and analysed every
month.
S-216 2003; 96; S-1–S-293
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EFFECTS OF ELECTROACUPUNCTURE ON PAIN-RELIEF of treatment (51 ± 13). After the each treatment, the CD4+/CD8+ ratio
AND THE DISTRIBUTION OF LYMPHOCYTE SUBSETS IN increased significantly compared to values before the each treatment
PATIENTS WITH CHRONIC LOW BACK PAIN (Table 1). However, these parameters had all returned to pre-EA values
before the next treatment.
AUTHORS: M. Yokoyama, Y. Itano, M. Hanazaki, S. Mizobuchi, H. DISCUSSION: EA treatment for 4 weeks (8 times) decreased pain
Nakatsuka, K. Morita score in patients with chronic low back pain during treatment, but pain-
AFFILIATION: Okayama University Medical School, Okayama City, relief was not sustained for a long period. Although a little change was
Japan. seen in the distribution of lymphocyte subsets after 20 min of EA, this
effect was transient even after 8 times treatments. The duration and the
INTRODUCTION: Electroacupuncture (EA) has been used for the indication of EA treatment should be further investigated.
treatments of chronic pain (1), and it is reported that EA modulates REFERENCES:
immune responses in animal model (2). However, effects of (1) Pain 86, 217-25, 2000.
acupuncture on pain-relief and immune-modulation remain in question. (2) Acupunct Electrother Res 24, 127-39, 1999.
The purpose of this study was to assess the effectiveness of EA as a
treatment for chronic low back pain. We also determined if EA affects Table 1. Changes in Lymphocyte Subsets (n = 20, #P < 0.05 vs before)
the immune response, particularly changes in the proportion of The first The first The last (8th) The last (8th) 1 month
lymphocyte subsets. before after before after later
METHODS: Twenty patients with low back pain participated in this
study. Patients who had back pain for more than 6 months and whose B cells (%) 17.8±7.0 19.2±6.3 18.1±6.5 19.5±6.6 18.9±5.8
pain intensity more than 40 on a visual analog scale (VAS: 0-100) were T cells (%) 67.2±8.5 69.0±8.3 66.9±8.0 68.5±8.3 66.0±8.1
chosen. Patients with the following diagnoses were excluded: CD4+ cells (%) 41.7±7.8 46.4±8.3 41.5±6.8 46.1±7.7 42.5±8.7
pregnancy, osteomyelitis of spine, tumor, ankylosing spondylitis,
vertebral fracture, and structural scoliosis. Participants received EA CD8+ cells (%) 25.5±4.5 21.4±5.4 25.5±4.0 22.5±4.6 23.5±4.1
treatment on a twice-weekly schedule for 4 weeks (8 times). A certified CD4+/CD8+ ratio 1.7±0.5 2.4±0.9# 1.7±0.4 2.2±0.8# 1.9±0.6
acupuncturist experienced in its application stimulated the participants NK cells (%) 15.0±4.9 11.8±5.3 15.0±4.2 12.0±4.3 15.2±5.4
with needles. The stimulus was biphasic wave at a frequency of 2-4 Hz
and was increased to the patient’s comfortable level for 20 min. Pain
level (VAS) was scored before the first, the forth, and the last treatments
and also at one month after the last treatment. Blood samples were
drawn before and after the first and the last treatment, and also at one
month later. The distribution of lymphocyte subsets was analyzed. Data
are expressed as mean ± SD. One-way analysis of variance or the
Kruskal-Wallis test was used for statistical analysis. Values were
considered statistically significant at P < 0.05.
RESULTS: Pain level was decreased significantly during treatments
(before, 58 ± 10; the forth, 44 ± 12, P < 0.01; the last, 37 ± 14, P < 0.01),
but pain level was returned to pre-EA value at one month after the end
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CONTINUOUS APPLICATION OF INTRATHECAL
MORPHINE IN PHANTOM PAIN
AUTHORS: P. Lierz1, A. Heinatz1, B. Gustorff2, P. Felleiter3
AFFILIATION: 1Marienkrankenhaus Soest, Soest, Germany, 2AKH,
Vienna, Austria, 3Swiss Paraplegic Centre, Nottwil, Switzerland.
A 55 year old patient suffering from stump pain and allodynia in the
area of his left knee and left shank for 14 years was treated with an
intrathecal infusion. During the continuous intrathecal application of 6
mg morphine/day the pain level decreased from VAS 9 to VAS 5 in two
days. After a intrathecal single shot of bupivacaine the pain didn’t
decrease. It took two weeks of continuous infusion to decrease the
allodynia to VAS 1-2 and two weeks more to enable the patient to start
walking with a prothesis. Testing the patient's response only by using
single shot applications of epidural or intrathecal local anesthetics and/
or opioids would have led to a negative conclusion. Only continuous
application of morphine resulted in a modulation of the pain memory.
We therefore conclude that testing of epidural or intrathecal drugs for
the treatment of neuropathic pain should be performed continuously
over several days and not using single shot applications.
2003; 96; S-1–S-293 S-218
S-217
INTERVENTIONAL PAIN MANAGEMENT ON POSTPOLIO PPS patients leads to progressive muscle and joint pain, myofascial
SYNDROME(PPS) spasm, sacroiliitis, facet arthropathy and radicular pain. There has been
series of reports on favorable outcome using physical therapy and
AUTHORS: E. S. Hsu exercise program, pharmacological or cognitive-behavior treatments on
AFFILIATION: UCLA, Los Angeles, CA. nonparalytic PPS pain management. Interventional pain management
on PPS patiens has not been well studied or documented. However,
INTRODUCTION: This a case study of four non-paralytic postpolio with the advance in fluoroscopic gudied spine injection, botulinum
syndrome (PPS) patients who were referred by primary care physicians toxins injection and radiofrequency neuroablation, PPS patients may
to anesthesiology pain management consult. All four patients are have more options to help chronic pain management. These procedures
female, age 50 to 59. Their chief complaints were daily aching and will cause less side effects in comparison to pharmacological approach.
cramping pain due to physicla activity, mainly involve trunk, hip, upper We look forward to seeing more well designed interventional pain
and lower limbs. These pain symptoms has not responded to research in PPS patients. This progress will certainly reduce suffering
conservative treatments e.g. oral analgesic, alternative medicine, and improve quality of life in PPS pain patients .
physical therapy and functional rehabilitation. REFERENCE:
METHODS: After initial evaluation and then further workups as 1.Halbritter T. J Am Acad Nurse Pract 2001 Dec;13(12):555-9
indicated, these four patients were found to suffer from myofascial 2.Klein MG et al. Arch Phys Med Rehabil 2000 Jun;82(6):789-95
spasm and pain syndrome, osteoarthritis, degenerative disc diease, facet 3.Widar M. Scand J Caring Sci 1999;13(1):33-4
arthropathy and sacroiliitis as common pain generators. Interventional 4.Willllen C et al. Arch Phys Med Rehabil 1998 Aug;79(8):915-9
pain treatment plans were recommended such as : trigger point
injections, sacroiliiac joint injection, facet median branch block, and
epidural steroid injection under fluoroscopic guidance. These four
patients and family members were very apprehensive about making
decision to take the interventional approach, because of the
neurological sequelae due to polio and PPS. The risks and benefits of
interventioal procedures were all discusse in detail.
RESULTS: There were noticeable pain relief and improvement in
functional capacity following the diagnostic nerve blocks or injections.
The radiofrequency neuroablation or other applicable interventional
approach was then recommended as next step. Psychological evaluation
and nonpharmacological pain coping strategies e.g. relaxation and
biofeedback were initiated and proved beneficial. Anxiolytics and
antidepresasants were popular choices in psychopharmacology
regimens. As far as the pharmacological pain management is
concerned, these four patients prefer to take long acting opioids and
only use short acting analgesics for breakthrough pain as needed. The
opioids requirement for optimal pain control were all decreased
following individual interventional pain management treatments.
DISCUSSION: Increasing muscular atrophy and joint instability in the
S-218
THE EFFECT OF TERRORISM ON CHRONIC PAIN AND affected by depression after 9/11/01 then were males as seen by the
DEPRESSION larger visit rates as demonstrated in the figure.
DISCUSSION: Acute stress induced by world events is associated with
AUTHORS: A. Buvanendran, A. Mehta, M. Moric, K. J. Tuman, T. an increase in visits to the chronic pain clinic in patients who have
R. Lubenow emotional and psychological issues of depression. This does not appear
AFFILIATION: Dept. of Anesthesiology, Rush Medical College, to occur in the absence of depression.
Chicago, IL. REFERENCES:
(1) JAMA 2002; 288: 633.
INTRODUCTION: Individuals directly exposed to the terrorist attacks
of September 11th, 2001 have a high probability of developing
posttraumatic stress disorder. However, even individuals not directly
exposed can experience a variable degree of trauma and stress (1).
Stress leads to a state of hyper-arousal and increased sympathetic
activity. This increased sympathetic activity can produce increased
muscle spasms and exacerbate neuropathic pain syndromes. We sought
to evaluate the effect of terrorism-induced stress on chronic pain
patients.
METHODS: After IRB approval, data were extracted from medical
records chosen from four epochs of time. The time period defining the
post terrorist attack interval begins on September 12 and ends on
October 11, 2001 (post 9/11/01). The immediately preceding time
period is defined as August 12 to September 11 (pre 9/11/01). The two
identical time intervals from the previous year (2000) were chosen for
comparative purposes and to control for seasonal trends. Each interval
comprises of 21 or 22 working days. Several variables, most notably,
patient visits, gender, and presence of depression (clinically
documented), were extracted and formed the basis of the analysis. A
factorial analysis of variances with pre-planed comparisons was
constructed to evaluate the data. Gender, depression (yes/no) and time
category make up the factors of the three-factor ANOVA.
RESULTS: Two thousand thirty nine patient visits total were identify
for all four time periods. Of those, 708 indicated depression as a
symptom for that visit. Pre-planed contrasts indicate that the post-9/11/
01 time category has a significantly higher mean visit rate compared to
each other time category {pre 9/11/01, post 9/11/00, pre 9/11/00} (P<
0.05). The two-way interactions of depression by time and depression
by gender were significant (P<0.01). Females were more greatly
Pediatric Anesthesia
Pediatric Anesthesia
S-220 2003; 96; S-1–S-293
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NASAL ADMINISTRATION OF REMIFENTANIL IMPROVES favorably with those after propofol induction. Ninety seconds were
CONDITIONS FOR INSERTION OF A LARYNGEAL MASK chosen in adults (and used in this study) because it represented the time
AIRWAY (LMA) FOLLOWING SEVOFLURANE INDUCTION at which all patients would have completed their vital capacity breath.
IN CHILDREN Remifentanil is commonly used by intravenous route to obtund the
airway response to tracheal intubation or LMA insertion in adults, and
AUTHORS: S. T. Verghese, R. S. Hannallah, M. P. Brennan, J. L. more recently following IV induction in children. The use of the
Yarvitz, K. M. Patel intranasal route to administer other lipophilic drugs (e.g. fentanyl and
AFFILIATION: Children's National Medical Center, Washington, DC. sufentanil) is well documented, especially before IV access is
established. Our preliminary results indicate that nasal administration of
INTRODUCTION: This study compares conditions for insertion of a remifentanil is a safe and potentially effective adjuvant technique to
Laryngeal Mask Airway (LMA) and airway response to LMA insertion facilitate LMA insertion in children.
(gagging, coughing and/or movement) after sevoflurane induction, with REFERENCES:
or without supplementary intranasal administration of one of three 1) Anesthesiology 1994; 81: 628-31.
doses of remifentanil (1,1.5 or 2 mcg/kg) vs. saline in children 1-<7 yr. 2) Anaesthesia 1999;54:271-6.
of age at 90 seconds following drug administration. 3) Anesth Analg 1999;88:908-12.
METHODS: Anesthesia was induced using nitrous oxide/oxygen and 4) Can J Anesth 1999;46:322-6.
8% sevoflurane. Sixty seconds later, nasal remifentanil (1,1.5 or 2 mcg/ 5) Anesth Analg 2001;92:S286.
kg) or saline was administered. Anesthesia induction continued with 5% 6) Anesth Analg 2002;94:S246.
sevoflurane in oxygen, with the child breathing spontaneously. A
principal investigator, who was blinded to the dose of remifentanil,
attempted LMA insertion 90 seconds after nasal drug administration,
and scored the response. End-tidal sevoflurane concentration was
recorded immediately before and after LMA insertion in each patient.
Following LMA insertion, ventilation was assisted using the same gas
mixture until the respiratory rate returned to base-line value, or for a
minimum of ten minutes, whichever occurred earlier.
RESULTS: To date, 52 patients have been studied. Good or excellent
conditions for LMA insertion were seen in 93% of patients who
received nasal remifentanil vs. 80% of controls. There was no
difference in end-tidal sevoflurane or CO2 concentration among patients
in the four groups. Patients who received remifentanil had significantly
lower respiratory rate from 5 until 10 minutes following nasal
administration vs. saline controls. There were no complications
associated with the nasal administration of study drugs. Serum
remifentanil levels at the time of LMA insertion are pending.
DISCUSSION: Conditions for LMA insertion in adults following a
single vital capacity breath of sevoflurane at 90 seconds compares
S-220
AUSCULTATION OF BILATERAL BREATH SOUNDS DOES The failure to diagnose main stem intubation by auscultation alone may
NOT RULE OUT ENDOBRONCHIAL INTUBATION IN be related to the use of Murphy eye ETTs. The Murphy eye was
CHILDREN designed to allow ventilation of the lung when the bevel of the ETT is
occluded. It has been demonstrated that the eye of the Murphy tube
AUTHORS: S. T. Verghese, R. S. Hannallah, R. R. Cross, M. Slack, G. reduces the reliability of chest auscultation in detecting endobronchial
R. Martin intubation.(2)
AFFILIATION: Children's National Medical Center, Washington, DC. Suggested measures for prevention of endobronchial intubation include
increased awareness of the imperfection of auscultation, assessment of
INTRODUCTION: Auscultation of equal and bilateral breath sounds insertion depth by checking length scale on the tube, and minimizing
suggests the position of an endotracheal tube (ETT) to be above the patient’s head and neck movement after intubation.
carina ventilating both lungs. Absolute confirmation of the tracheal tube REFERENCES:
position is possible by fluoroscopy. 1) Crit Care Med 1990;18:760-3.
METHODS: Oro-tracheal intubation was performed in 72 consecutive 2) Anesth Analg 1999;88:1380-3.
patients undergoing cardiac catheterization. The ETT was taped at a
level appropriate to the child’s age based on standard formulae.
Auscultation of bilateral breath sounds was confirmed. The relationship
of the tip of the ETT to the carina was determined during fluoroscopy.
RESULTS: 49 patients (68.1%) were under 120 months, and 10
(13.9%) were infants under 12 months of age. By fluoroscopy the tip of
the ETT was seen in the right mainstem bronchus in 11 patients (15.3%)
and in a low position above the carina in 14 patients (19.4%). Out of the
11 patients with right mainstem intubation, 10 were children <120
months of age and 4 were less than 12 months of age. (Fisher’s exact
test P=0.040). There was a direct correlation between the age and
weight of the patient and the incidence of low tracheal and right main
bronchial intubation (P=0.005 and P= 0.004, respectively). There was
no association between the experience of the anesthesia trainee and the
incidence of right mainstem intubation.
DISCUSSION: Achieving appropriate ETT positioning in children is
not always easy because the tracheal length of a child is shorter than
that of an adult. Moreover, the position of the ETT is easily altered by
head position, rotatory movements, and flexion as well as extension of
the head. In one study, ETT malposition rates observed in ICU
postintubation chest radiographs were 39.1% after positioning guided
by clinical assessment alone.(1) Endobronchial intubation, or an ETT
that is low enough to touch the carina, may precipitate coughing,
bronchial spasm, arterial oxygen desaturation and patient's movement.
2003; 96; S-1–S-293 S-222
S-221
DIRECTION OF THE NEEDLE INSERTION IN AN INTERNAL
JUGURAR VEIN PUNCTURE, RADIOGRAPHIC
CONSIDERATION
AUTHORS: T. Mori, T. Arai, M. Yamashita
AFFILIATION: Ibaraki Children's Hospital, Mito City, Japan.
INTRODUCTION: Placement of central venous line via the right
internal jugular vein (RIJV) is widely practiced in anesthesia for open-
heart surgery in infants and children. Direction of puncture needle is
generally described as toward the ipsilateral nipple (1). We studied the
relationship of this direction and right internal jugular vein anatomy.
METHODS: The protocol was approved by the local ethics committee
and written informed consent was obtained from parents. Thirty-two
patients scheduled for cardiac catheterization were studied. After
routine cardiac catheterization, markers were placed on the insertion
site of the RIJV puncture (high approach) and the right nipple, then
right internal jugular venogram (2) was obtained. The anatomical
relationship was examined on the film.
RESULTS: The age, weight and height of subjects were 0 month to 13
years, 3.5 kg to 50.4kg, and 51.3 to 153.2 cm, respectively. The angle
between the line on the RIJV and the line drawn from the insertion site
to the nipple was 30.6 ± 7.3 degrees. The RIJV run essentially parallel
to the long axis of the body.
DISCUSSION: The line on the RIJV and the line from the insertion
site to the right nipple were not identical at all. The direction of the
puncture needle of the internal jugular vein could be parallel to the long
axis of the body, i.e. the line on the internal jugular vein.
REFERENCES:
1.Anaesthesia 44; 170-174,1976.
2. Anesth Analg 93:331-334,2001
S-222
ANESTHETIC IMPLICATIONS OF EPICARDIAL cardiac output and did not receive inotrope preoperatively or in the
PACEMAKER PLACEMENT IN NEONATES WITH operating room prior to the hypotension, and 1/4 (AH) developed
CONGENITAL COMPLETE HEART BLOCK hypotension despite preoperative intubation, inotrope and TEPW. 5/17
patients received atropine intraoperatively, without an increase in heart
AUTHORS: B. D. Kussman, D. R. Madril, E. P. Walsh, P. C. Laussen rate. The response to catecholamines was less than anticipated in 1 NH
AFFILIATION: Children's Hospital, Boston, MA. and 3 AH. Transcutaneous pacing was not used in any patient. There
was one death (6%, 0/11 NH, 1/6 AH) and all other patients survived to
INTRODUCTION: Congenital complete heart block (CCHB) carries discharge.
high neonatal morbidity (58%) and mortality (7%)1. Placement of a DISCUSSION: Patients with a structurally abnormal heart, baseline
permanent epicardial pacemaker (EPM) soon after birth may be ventricular escape rate <40 bpm, low cardiac output state, and/or
necessary but can be associated with significant hemodynamic extreme prematurity pose the greatest perioperative risk for
instability2; our experience in neonates with CCHB undergoing hemodynamic instability. When these factors are present, mechanical
anesthesia for EPM placement is described. ventilation, invasive monitoring, inotropic support and temporary
METHODS: A retrospective chart review of neonates with CCHB who pacing should be considered early. Atropine appears to offer no benefit,
underwent anesthesia for EPM at Children's Hospital between 1988 and and the response to catecholamines diminished.
2001 was performed. Demographic and perioperative data were REFERENCES:
examined; hypotension was defined as a 20% decrease from baseline. 1. Pediatrics, 106 (1), 86, 2000.
RESULTS: Seventeen neonates were identified, 11 with structurally 2. Paediatric anaesthesia, 7, 301, 1997.
normal hearts (NH, 65%) and 6 with structurally abnormal hearts (AH,
35%; heterotaxy n=5, VSD n=1). Demographic data (mean) of NH vs.
AH respectively included: gestational age 36.7 vs. 35.3 weeks, weight
2.9 vs. 2.5 kg, and age at surgery (day of life, DOL) 4.2 vs. 3.3.
Mechanical ventilation and inotropic support were needed
preoperatively in 8 patients (3/12 with NH (25%) and 5/6 with AH
(83%)), and 2/8 were extremely premature (26 wks NH and 30.6 wks
AH). Temporary epicardial pacing wires (TEPW), placed in the ICU via
a small subxyphoid incision, were necessary for 4/6 (75%) of the AH
group on DOL 1 because of low ventricular escape rate <40 bpm and
clinical signs of a low cardiac output. All patients had a permanent
epicardial VVI pacemaker placed through an extended subxyphoid
incision. In the NH group, 7/11 received balanced general anesthesia -
induction with ketamine (n=6) or thiopentone (n=1), and maintenance
with N2O/O2 and volatile agent. The remaining 4 NH and all 6 AH
neonates received a narcotic-based technique (fentanyl 12- 66 mcg/kg)
supplemented with N2O, midazolam and/or low concentrations of
isoflurane. Intraoperative hypotension occurred in 4 patients, 2 with NH
(16.7%) and 2 with AH (33.3%); 3/4 had clinical evidence of low
S-224 2003; 96; S-1–S-293
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A RETROSPECTIVE REVIEW OF PERIOPERATIVE FRESH Specialty Similar Possibly similar Dissimilar
FROZEN PLASMA TRANSFUSION PRACTICE IN A
Orthopedics 12 4 8
CHILDREN'S HOSPITAL
Cardiac 18 1 14
AUTHORS: U. R. Parekh, W. Splinter General surgery 8 4 7
AFFILIATION: Children's Hospital of Eastern Ontario, Ottawa, ON,
Neurosurgery 1 2 3
Canada.
Others 4 - 5
INTRODUCTION: Fresh frozen plasma (FFP) continues to be
Time
overused and also used inappropriately1,2 despite its supply being finite.
Moreover, medicolegal implications of transfusion-transmitted disease Preoperative 9 2 9
reinforce the need for recognized and defensible transfusion criteria. In Intraoperative 16 4 15
1997 Canadian Medical Association published recommendations for Postoperative 17 5 18
appropriate use of red cells and plasma transfusion in adults and
children over 4 months of age.3 As a part of quality assurance program DISCUSSION: Forty-two percent of the transfusion episodes were
we undertook this audit to determine how our perioperative practice of dissimilar to the guidelines. Unfortunately, such a high rate is similar to
transfusion of fresh frozen plasma in children conformed with those reported in previous studies.4-7 Since earlier studies use different
published criteria. guidelines and include adult population, the results of this study are not
METHODS: From the guidelines published by the Canadian Medical directly comparable. We were surprised to identify situations where
Association we laid down the guidelines relevant in the perioperative FFP was inappropriately transfused. Guidelines for transfusion
period3. FFP perioperative transfusion episodes for 100 consecutive appropriateness, education of hospital staff and a monitoring system to
patients greater than 6 months of age admitted to our children‘s hospital ensure adherence to guidelines, are required.
for elective or emergency surgical procedure during the years 1999- REFERENCES:
2000 were evaluated. Each transfusion episode was rated as being 1. J Clin Pathol 1991; 44(9): 734-7.
similar, possibly similar or dissimilar to the guidelines. Transfusion 2. Med J Aust 1995;162: 572-577.
episodes were also classified according to surgical specialty and by the 3. CMAJ 1997;156(11 Suppl): S1-S24.
time it was given i.e. preoperatively, intraoperatively and 4. Transfusion 1986;26(6):511-3.
postoperatively. 5. Transfus Med 1998;8(1):37-41.
RESULTS: The 100 transfusion episodes accounted for 170 units 6. CMAJ 1989;140(7):812-15.
transfused to 82 children. Of the 100 transfusion episodes, 42 were 7. Transfusion 1989;29(6):473-6
judged similar, 11 possibly similar, 42 dissimilar to the guidelines and 4
had inadequate information to be judged. Of the 170 units transfused,
69(41%) were judged similar, 17(10%) possibly similar, 68(40%)
dissimilar to the guidelines and 5% had inadequate information.
Analysis of transfusion episode by specialty and time of transfusion is
as follows
S-224
TO SWADDLE OR NOT: NOT ALL CHILDREN BECOME nearly 42% of patients in our study did not become hypothermic (T>
HYPOTHERMIC DURING MRI SCANNING UNDER 36.1 C) even when only covered with a hospital gown and cotton
GENERAL ANESTHESIA blanket. Patients likely to stay warm were older, had a greater body
mass and underwent shorter scans than those who became hypothermic.
AUTHORS: Y. Bryan, M. Drum, O. Gottlieb, T. Templeton, D. These results suggest that the absorption of energy during the scan may
Coalson play a significant role in temperature fluctuations during general
AFFILIATION: University of Chicago, Chicago, IL. anesthesia for MRI procedures. (3) Further studies are needed to
understand the mechanism of heat exchange in children during MRI
INTRODUCTION: The cool dry environment, circulating air within procedures.
the magnet bore, and inability to use active warming devices REFERENCES
characteristic of MRI scanning increases the risk of hypothermia during 1. J Magn Reson Imaging 2000;12:30-36
general anesthesia. Absorption of radiofrequency radiation during the 2. Radiology 1987;163:259-262
scan, however, may counteract this effect. (1,2) As routine temperature 3. BJR 1989;62:904-909
monitoring is not possible due to the magnetic field, little is known
about temperature fluctuations during MRI procedures. We sought to
determine the incidence of hypothermia in children after MRI‘s under
general anesthesia.
METHODS: With IRB approval, we prospectively studied 50 children
who underwent MRI studies under general anesthesia. The ages ranged
from 1 month to 18 years and weights from 1.4 to 89 kg. Induction and
emergence occurred in a room adjacent to the MRI where the ambient
temperature ranged from 22-24 C. 44 patients were induced with
sevoflurane with LMA placement. 6 received propofol or ketamine for
induction and were intubated. Maintenance was with sevoflurane with
patients breathing spontaneously. The children were covered with a
hospital gown and cotton blanket; no other heating device was used.
Rectal temperatures were measured immediately after induction prior to
MRI and after MRI prior to emergence from general anesthesia.
RESULTS: 21/50 children (42%) had post-scan rectal temperatures >
36.1 C. Patients with rectal temperatures > 36.1 C were older (7.2 +/-
3.7 vs 4.6 +/- 3.8 years ) , had greater body mass ( 32.2 +/- 20.9 vs 22.2
+/- 17.2 kg ), and shorter MRI scans ( 43.4 +/- 15.2 vs 63.4 +/- 22.9
minutes). The type of anesthesia and frequency of endotracheal
intubation did not differ between groups.
DISCUSSION: Although the MRI environment and general anesthesia
in children may increase the risk of heat loss, radiofrequency radiation
may cause an increase in the heat gain by the patient. We found that
2003; 96; S-1–S-293 S-226
S-225
EVALUATION OF AN OBSERVATIONAL DATABASE FOR patients (75%) had Foley catheters immediately after surgery; however,
OUTCOMES WITH EPIDURAL ANALGESIA IN PEDIATRIC 50% (n=19) of patients age 0-3 years did not have Foley catheters and
POST-SURGICAL PATIENTS were voiding spontaneously. Overall, respiratory depression, defined as
a respiratory rate <10/min, was not detected in any patient immediately
AUTHORS: P. M. McQuillan, C. M. Gelnett, H. Schuler, N. A. after surgery or on POD 1 and 2. Mild side effects from local anesthetic
DiVittore, R. C. Polomano, F. K. Orkin (e.g., metallic taste, tinnitis) were noted in 1 patient (0.9%). Pairwise
AFFILIATION: Milton S. Hershey Medical Center, Penn State comparisons with the Mann-Whitney U test revealed better motor
University College of Medicine, Hershey, PA. strength on POD 1 and 2 for the 0-3 year group compared to those 4-9
years (p<0.01) and 10-17 years (p<0.01).
INFORMATION: Little is known about safety and effectiveness of DISCUSSION: In a prospective evaluation of pediatric patients
continuous epidural analgesia for postoperative pain control in infants receiving epidural analgesia, we found no dural punctures or catheter-
and children. McBride, et al.1 evaluated 19 children (ages 4-17 years) related infections. Assessments of children >3 years who were able to
receiving continuous epidural infusions, 17 via thoracic catheters, provide self-report data yielded no evidence of headache, pain at
following pectus deformity repair. They reported excellent pain control injection site, or new neurological deficits. Our findings show that
and no catheter-related complications. We describe our experience with epidural analgesia provides excellent pain control without significant
a larger number of patients, including children <4 years of age and risks for adverse side effects and complications.
those undergoing a variety of surgical procedures. REFERENCES:
1
METHODS: We developed an observational database to monitor and McBride, et al. J Ped Surg 1996;31:105-107.
track analgesia-related outcomes for a consecutive series of pediatric
surgical patients followed by our Acute Pain Management Service.
Information was recorded on clinical outcomes such as pain severity,
sedation, nausea and vomiting (N/V), pruritis, respiratory depression,
urinary retention and motor impairment, and practice variables (e.g.,
catheter level, epidural solution). Using nonparametric statistics, we
examined outcomes from the entire sample (110 to date; 70 female) and
by age groups [0-3 years (n=38), 4-9 (n=36), and 10-17 (n=36)], and
compared severity of adverse effects using the Mann-Whitney U test.
RESULTS: The majority of subjects received continuous epidural
infusions with bupivacaine 0.1%; 94.7%, 94.4% and 75%, respectively
by age group. Most children >3 years underwent orthopedic procedures
with a combination of regional and general anesthesia; level of catheter
placement included thoracic (n=24), lumbar (n=49) and caudal (n=30).
Eighty percent of patients <4 years had caudal catheters. Daily pain
scores were similar between children 4-9 years and 10-17 years, with
mean scores in the range of none to mild pain through postoperative day
(POD) 2. No differences were observed for the severity of N/V,
sedation, and pruritis, which if present, were mild. The majority of
S-226
EFFICACY OF SOMATIC PARAVERTEBRAL BLOCK FOR mean+SD, P<0.001. The time to first dose of morphine after surgery
POSTOPERATIVE PAIN RELIEF IN CHILDREN was greater in the SPVB group, 7.1+4.4. vs 2.5+1.6 hr, mean+SD,
UNDERGOING OPEN APPENDECTOMY P<0.001. Two patients in the SPVB-group and 5 control-patients
vomited. None of the SPVB-treated patients had an adverse event
AUTHORS: K. M. Chowdary, W. M. Splinter secondary to their regional block.
AFFILIATION: Children's Hospital of Eastern Ontario, Ottawa, ON, CONCLUSION: This study shows that SPVB is an effective method
Canada. of pain relief in children undergoing open appendectomy. SPVB can
effectively increase postoperative analgesia and decrease the use of
INTRODUCTION: Post operative pain relief is a major concern for opioid medication that can obviate the incidence of undesirable side
pediatric anesthesiologists. Poor pain control causes patient and parent effects. A formal prospective investigation appears indicated.
anxiety, dissatisfaction and delayed discharge. Pain management REFERENCES:
options include opioids, which may lead to vomiting and respiratory 1. Anaesthesia, 1995; 50: 813-5.
depression and adjuvant regional analgesia. Somatic paravertebral 2. Anaesthesia, 2001; 56: 1181-8.
block (SPVB) has been used for analgesia in children (1-3). We 3. Anaesthesia, 1993; 48(1):93.
conducted a chart review to assess the effectiveness of SPVB for
postoperative pain relief in children undergoing open appendectomy.
METHODS: We reviewed 36 consecutive charts of children between
the ages 3-16 years undergoing open appendectomy under general
anesthesia in this case-control study. In both groups, rapid sequence
induction of anesthesia was with IV propofol 2.5 mg/kg and
succinylcholine 1.5 mg/kg. General anesthesia was maintained with
isoflurane 1% in 70% N2O and O2. All patients were given fentanyl 2
mcg/kg IV, ketorolac 0.5mg/kg IV, and acetaminophen 20 mg/kg PR
before incision. SPVB was performed by, or under supervision of, one
of the investigators, at T 11, T12, L1 level using 22 G Touhy needle in left
lateral decubitus position before incision. Ropivacaine 0.2% with
epinephrine 1:200,000 in an amount of 0.25 ml/kg (maximum of 5 ml)
was injected at each level. Charts were reviewed for the first 24 hours
after surgery. In the postoperative period analgesia was provided with
morphine 0.05 mg/kg IV q 2 hrs in a structured manner when VAS pain
scores were greater > 6/10. A record of time to the first dose of
morphine required after surgery and total requirement of morphine in
first 24 hr were recorded. Any adverse effects including nausea,
vomiting or respiratory depression were noted.
RESULTS: Demographic data, such as age, weight, gender, and length
of surgery, were similar. SPVB treated-patients required less total
morphine during the first 24 hr, 0.12+0.07 vs 0.34+0.15mg/kg/24hr,
2003; 96; S-1–S-293
S-227
CAUDAL ANALGESIA MODIFIES THE EFFECT OF performed and Recovery time and Recovery score were recorded as
FLUMAZENIL ON RECOVERY FROM SEVOFLURANE well.
ANESTHESIA AFTER ORAL MIDAZOLAM RESULTS:
PREMEDICATION
AUTHORS: H. Okamura, K. Oguri, K. Kawase, T. Kitagawa, Y. Children without caudal
Children with caudal analgesia
Fujiwara analgesia
AFFILIATION: Nagoya First Red Cross Hospital, Nagoya, Japan. Control Flumazenil
Flumazenil group Control group
group group
INTRODUCTION: Oral premedication with midazolam in children Recovery score 5.0 ± 0.4 5.1 ± 0.4 5.3 ± 0.6* 7.7 ± 0.4
provides satisfactory anxiolysis before anesthesia (1), but delays
recovery after brief sevoflurane anesthesia (2). Flumazenil, a potent Recovery time 2.3 ± 0.4* 4.7 ± 0.6 4.3 ± 0.4* 6.1 ± 0.7
benzodiazepine antagonist, can reverse the sedative effect of
midazolam-induced anesthesia (3). So our first purpose was to evaluate Values are means ± SEM, *p<0.05 vs control group
the effect of flumazenil on recovery after sevoflurane anesthesia in DISCUSSION: Recovery from sevoflurane anesthesia occurred earlier
children premedicated with midazolam orally. As we found that by flumazenil administration in children premedicated with midazolam
flumazenil shortened the recovery time without affecting the quality of regardless of the application of caudal analgesia. Flumazenil did not
recovery, our second purpose was to investigate if the effect of affect the quality of recovery in children without caudal analgesia but
flumazenil is modified by caudal analgesia. resulted in more agitated recovery in children with caudal analgesia.
METHODS: 30 children (1-8 years, ASA physical status 1 or 2) REFERENCES:
undergoing lower abdominal procedure were randomly assigned to (1) Anesth Analg 1992; 75: 51-5
flumazenil group and control group. They were premedicated with 0.5 (2) Anesth Analg 1999; 89: 75-9
mg/kg midazolam orally approximately 30 minutes before the induction (3) J Pediatric 1997; 131: 582-6
of anesthesia. Anesthesia was induced and maintained with sevoflurane
(3-5%) and nitrous oxide (66%), in oxygen via a face mask with
spontaneous breathing. Sevoflurane was discontinued at the beginning
of skin closure, and then at the end of surgery nitrous oxide was
discontinued and flumazenil 0.02 mg/kg or saline was injected. The
time from discontinuation of anesthesia to grimacing at tactile
stimulation (Recovery time) was recorded. At the time of discharge
from operating room, a blinded observer evaluated the quality of
recovery as Recovery score, which was sum of the three objective
components: sedation (1 = awake; 2 = drowsy; 3 = asleep), crying (1 =
panicky; 2 = moaning; 3 = not crying), and movement (1 = thrashing; 2
= restless; 3 = none). In other 30 children (1-8 years, ASA physical
status 1 or 2) who had caudal analgesia with 1 ml/kg of 0.25%
bupivacaine after anesthesia induction, the same protocol as above was
Pharmacology –
Basic Science
Pharmacology -
Basic Science
S-229 2003; 96; S-1–S-293
S-228
FELINE PULMONARY VASCULAR RESPONSES TO
EPHEDRINE
AUTHORS: T. A. Richards, A. M. Fields, I. N. Ibrahim, A. D. Kaye
AFFILIATION: Texas Tech University School of Medicine, Lubbock,
TX.
Pulmonary vascular responses to ephedrine, phenylephrine, and
U46619, and their effects after administration of the non-selective 1
antagonist, prazosin, the 1B antagonist, chloroethylclonidine, and the
selective 1D antagonist, BMY 7378, were investigated in the intact-
chest under constant flow conditions in anesthetized cats. Ephedrine,
phenylephrine, and U46619, a thromboxane A2 mimic, all produced
dose-dependent vasoconstrictor responses in the feline pulmonary
vascular bed. After administration of prazosin, in a dose of 1 mg/kg iv,
there was no significant change in U46619-induced vasopressor
responses; however, there was significant attenuation of pulmonary
vasoconstrictor effects induced by ephedrine and phenylephrine. The
effects of the selective 1B antagonist chloroethylclonidine, in a dose of
0.3 mg/kg iv, were evaluated in a separate protocol. Pulmonary
vasoconstrictor responses to ephedrine and phenylephrine were
attenuated after the administration of chloroethylclonidine. However,
no significant attenuation of the pulmonary vasopressor responses to
U46619 was demonstrated. In a third protocol, the effects of the
selective 1D antagonist BMY 7378, in a dose of 0.3 mg/kg iv, were
evaluated. The vasopressor effects of ephedrine, phenylephrine and
U46619 were unchanged after the administration of BMY 7378. These
data suggest that ephedrine and phenylephrine induce pulmonary
vasoconstriction in the cat and that this response is mediated, in part, by
an 1 receptor-sensitive mechanism. Furthermore, this constrictor
response is mediated by the 1B receptor and not the 1D receptor.
S-229
ANALYSIS OF THE GABAA RECEPTOR AGONIST, response is mediated, in part, by a GABAA receptor-sensitive
MUSCIMOL, IN THE PULMONARY VASCULAR BED OF THE mechanism and not the GABAB receptor.
CAT
AUTHORS: T. A. Richards, A. M. Fields, I. N. Ibrahim, A. D. Kaye
TX.
Pulmonary vascular responses to a GABAA selective agonist,
muscimol, bradykinin, and the potassium channel opener, pinacidil, and
their effects after administration of the ATP-sensitive potassium channel
blocking agent, glibenclamide (5 mg/kg iv), the nitric oxide synthase
inhibitor, L-N5-(1-iminoethyl) ornithine (L-NIO) (1mg/kg iv), the
cyclooxygenase inhibitor, meclofenamate (2.5 mg/kg iv), the GABAA
antagonist, bicuculline (0.1 mg/kg iv), and the GABAB antagonist,
saclofen (0.1 mg/kg iv), were investigated in the intact-chest cat under
constant flow conditions. Muscimol, bradykinin, and pinacidil all
produced dose-related decreases in lobar arterial pressure under high
tone conditions after administration of an infusion of U46619, a
thromboxane mimic. Following administration of glibenclamide, in a
dose that significantly attenuated pinacidil-induced vasodepressor
responses, muscimol and bradykinin were not significantly affected.
Following administration of L-NIO, in a dose that significantly reduced
bradykinin-induced vasodepressor responses, muscimol and pinacidil-
induced vasodilatation was not significantly attenuated. After
administration of meclofenamate, in a dose that significantly reduced
arachidonic acid induced vasodepressor responses, pinacidil,
bradykinin, and muscimol-induced vasodilatation was not significantly
attenuated. After administration of the GABAB antagonist, saclofen,
there was no alteration on muscimol, pinacidil, or bradykinin responses.
Finally, after administration of the GABAA antagonist, bicuculline,
there was no alteration on bradykinin or pinacidil responses; however,
muscimol-induced vasodepressor effects were significantly attenuated.
These data suggest that muscimol induces pulmonary vasodepressor
responses in the pulmonary vascular bed of the cat and that this
2003; 96; S-1–S-293 S-231
S-230
THE EFFECTS OF NOREPINEPHRINE IN THE PULMONARY
VASCULAR BED OF THE CAT
AUTHORS: A. M. Fields, T. A. Richards, I. N. Ibrahim, A. D. Kaye
TX.
Pulmonary vascular responses to norepinephrine, phenylephrine, and
U46619, and their effects after administration of the non-selective 1
antagonist, prazosin, the 1B antagonist, chloroethylclonidine, and the
selective 1D antagonist, BMY 7378, were investigated in the intact-
chest under constant flow conditions in anesthetized cats.
Norepinephrine, phenylephrine, and U46619, a thromboxane A2 mimic,
all produced dose-dependent vasoconstrictor responses in the feline
pulmonary vascular bed. After administration of prazosin, in a dose of 1
mg/kg iv, there was no significant change in U46619-induced
vasopressor responses; however, there was significant attenuation of
pulmonary vasoconstrictor effects induced by norepinephrine and
phenylephrine. The effects of the selective 1B antagonist
chloroethylclonidine, in a dose of 0.3 mg/kg iv, were evaluated in a
separate protocol. Pulmonary vasoconstrictor responses to
norepinephrine and phenylephrine were attenuated after the
administration of chloroethylclonidine. However, no significant
attenuation of the pulmonary vasopressor responses to U46619 was
demonstrated. In a third protocol, the effects of the selective 1D
antagonist BMY 7378, in a dose of 0.3 mg/kg iv, were evaluated. The
vasopressor effects of norepinephrine, phenylephrine and U46619 were
unchanged after the administration of BMY 7378. These data suggest
that norepinephrine and phenylephrine induce pulmonary
vasoconstriction in the cat and that this response is mediated, in part, by
an 1 receptor-sensitive mechanism. Furthermore, this constrictor
response is mediated by the 1B receptor and not the 1D receptor.
S-231
MA HUANG VASOPRESSOR EFFECTS ARE MEDIATED BY
AN ALPHA1B RECEPTOR IN THE PULMONARY VASCULAR
BED OF THE CAT
AUTHORS: A. M. Fields, T. A. Richards, I. N. Ibrahim, A. D. Kaye
TX.
Pulmonary vascular responses to the herbal stimulant, Ma Huang,
phenylephrine, and U46619, and their effects after administration of the
non-selective 1 antagonist, prazosin, the 1B antagonist, chloroethyl-
clonidine, and the selective 1D antagonist, BMY 7378, were
investigated in the intact-chest under constant flow conditions in
anesthetized cats. Ma Huang, phenylephrine, and U46619, a
thromboxane A2 mimic, all produced dose-dependent vasoconstrictor
responses in the feline pulmonary vascular bed. After administration of
prazosin, in a dose of 1 mg/kg iv, there was no significant change in
U46619-induced vasopressor responses; however, there was significant
attenuation of pulmonary vasoconstrictor effects induced by Ma Huang
and phenylephrine. The effects of the selective 1D antagonist BMY
7378, in a dose of 0.3 mg/kg iv, were evaluated. The vasopressor effects
of Ma Huang, phenylephrine and U46619 were unchanged after the
administration of BMY 7378. In a third protocol, the effects of the
selective 1B antagonist chloroethylclonidine, in a dose of 0.3 mg/kg iv,
were evaluated in a separate protocol. Pulmonary vasoconstrictor
responses to Ma Huang and phenylephrine were attenuated after the
administration of chloroethylclonidine. However, no significant
attenuation of the pulmonary vasopressor responses to U46619 was
demonstrated. These data suggest that the herbal stimulant, Ma Huang,
and phenylephrine induce pulmonary vasoconstriction in the cat and
that this response is mediated, in part, by an 1 receptor-sensitive
mechanism. Furthermore, this constrictor response is mediated by the
1B receptor and not the 1D receptor.
S-233 2003; 96; S-1–S-293
S-232
MODULATION OF VALERIAN ON BRAINSTEM GABAERGIC induced by muscimol (30 M).
EFFECTS IN RATS DISCUSSION: Valerian may act as a sedative via modulation of
GABA neurotransmission and receptor function (4). Our results
AUTHORS: C. Yuan1, A. Wang1, S. Mehendale1, S. Maleckar1, M. demonstrated the interactions of valerian extract with ligand-bindings
Ang-Lee2 of GABAA receptors and the modulation of the brainstem GABAergic
AFFILIATION: 1Department of Anesthesia and Critical Care, mechanism by valerian. It seems that valerian may interfere with
University of Chicago, Chicago, IL, 2Western Washington Medical GABAergic neurotransmission, and presurgical valerian use may cause
Group, Everett, WA. valerian-anesthetic interaction during perioperative care (2).
REFERENCES:
INTRODUCTION: Valerian is an herb native to the temperate areas of (1) J Pharm Pharmacol 1999;51:505-512.
the Americas, Europe, and Asia. Valerian is a commonly used herbal (2) JAMA 2001;286:208-216.
medicine to treat insomnia and anxiety (1), and thus, it may potentiate (3) J Pharmacol Exp Ther 2002;301:488-493.. 1998;286:736-741.
sedative effects of anesthetics (2). We hypothesized that there is an (4) Neurochem Res 1999;24:1373-1378.
interaction between valerian activity and GABAergic mechanism in the (Supported in part by the NIH grant AT 381 and the Tang Family
brainstem neurons. In this study, we evaluated the effects of valerian Foundation.)
and GABAA receptor agonist, muscimol, on brainstem neuronal
activities.
METHODS: Experiments were performed on neonatal rats of 1 to 5
days old. After the animal was deeply anesthetized with halothane, a
craniotomy was performed and the forebrain was ablated at the caudal
border of the pons by transection. The caudal brainstem and cervical
spinal cord were isolated by dissection in modified Krebs solution. The
bathing solution was equilibrated with 95% O2 and 5% CO2 and
adjusted to pH 7.4. Single tonic unitary discharges to valerian extract
(from Lichtwer Pharma AG, Germany) were recorded in the nucleus
tractus solitarius (NTS) in the brainstem by glass microelectrodes (3).
RESULTS: Muscimol, GABAA receptor agonist, inhibited the
spontaneous activity of the majority of the NTS units. This inhibition
(approximately 57% compared to 100% of the control level; IC50 = 30
M) could be antagonized by selective GABAA receptor antagonist,
bicuculline (10 M). Application of valerian extract into the brainstem
compartment of the preparation also significantly reduced the discharge
rate of these NTS neurons (approximately 32% compared to the control
level; IC50 = 1.0 mg/ml), and this reduction could partially be reversed
by bicuculline (10 M). Pretreatment with 1.0 mg/ml valerian extract
significantly decreased the NTS inhibitory effects (from 57% to 32%)
S-233
THE RELATIONSHIP BETWEEN DOPAMINERGIC NEURO- abolished, and aggravation of ischemic neuronal damage by
TRANSMISSION INNERVATION AND DEXAMETHASONE- dexamethasone was completely alleviated.
INDUCE AGGRAVATION OF ISCHEMIC NEURONAL DISCUSSION: Because the striatum is predominantly innervated by
DAMAGE IN THE RAT STRIATUM dopaminergic fibers, the facilitation of ischemic release of dopamine by
dexamethasone may be a contributing factor in the aggravation of
AUTHORS: T. Mitsuyo, N. Adachi, T. Arai ischemic in the striatum. The administration of glucocorticoids in
AFFILIATION: Ehime University school of Medicine, Shigenobu, cerebral ischemia may be harmful.
Japan.
INTRODUCTION: Glucocorticoids have been reported to aggravate
ischemic neuronal damage in both humans and experimental animals.
The agents also increase activity of the central dopaminergic system.
Because excess release of dopamine in cerebral ischemia is closely
related to the outcome of neuronal damage, the authors examined the
relationship between dexamethasone-induced facilitation of
dopaminergic activity and histologic outcome.
METHODS: Changes in the extracellular concentration of dopamine
and its metabolites in the striatum produced by occlusion of the middle
cerebral artery for 20 minutes were investigated by a microdialysis---
high-performance liquid chromatography procedure and effects of
intracerebroventricular administration of dexamethasone (10 µg) were
evaluated in halothane-anesthetized rats. The histologic outcome was
examined 7 days after ischemia by light microscopy. In another set of
rats, the substantia nigra was lesioned 2 days before, and identical
procedures were applied to these animals to assess the relationship
between changes in ischemic release of dopamine and morphology.
RESULTS: The occlusion of the middle cerebral artery produced a
marked increase in the extracellular concentration of dopamine in the
striatum, the peak value being 240 times that before ischemia. The
value returned to the basal level immediately after reperfusion. The
preischemic administration of dexamethasone enhanced the increase in
the dopamine level during ischemia, and the peak value in the
dexamethasone group was 640% of that in the vehicle group. The value
returned to the basal level 2 h after reperfusion. After 7 days, ischemic
neuronal damage in the dexamethasone group was severe compared
with that in the vehicle group. In rats receiving the substantia nigra
lesion and dexamethasone treatment, ischemic release of dopamine was
2003; 96; S-1–S-293 S-235
S-234
LOW DOSE BUPRENORPHINE ENHANCE THE SPASTIC
PARAPARESIS INDUCED BY INTRATHECAL MORPHINE
AFTER NON- INJURIOUS INTERVAL OF SPINAL ISCHEMIA
IN RATS
AUTHORS: S. Nakamura1, M. Kakinohana1, T. Fuchigami2, K.
Sugahara1
AFFILIATION: 1Department of Anesthesiology, University of
Ryukyus, Okinawa, Japan, 2Kokura Kinen Hospital, Fukuoka, Japan.
INTRODUCTION: We have recently reported that intrathecal (IT)
injection of morphine (Mor) after non-injurious interval of spinal
ischemia induced transient spastic paraparesis in rats(1). This effect was
reversed by subsequent IT naloxone administration, suggesting that
spinal opioid receptor play an active role in the spinal functional
dysinhibition initiated by transient spinal ischemia. It was reported that
Bup play some role in the analgesic actions of mu-opioid agonists in the the other hand, the combination with IT 0.2micg Bup and 0.3micg Mor
spinal cord same as morphine(2). (3)However,we reported IT progressed a spasticity, resuting in complete paraparesis (Figure).
buprenorphine (Bup) 4micg did not induce spastic paraparesis after CONCLUSION: Our results demonstrated that low dose IT Bup
non-injurious interval of spinal ischemia (4). Therefore, we enhance the spastic paraparesis induced by morphine after non-
hypothesized that low dose IT Bup and Mor has interactive effect for injurious interval of spinal ischemia in the rat. We suggest that the small
the spastic paraparesis. The aim of this study was to characterize the dose morphine can induce spastic paraparesis in combined with
interaction between low dose IT Bup and Mor after non-injurious buprenorphine.
interval of spinal ischemia in rats. REFERENCES:
METHODS: In using rats implanted with IT catheter, the placement (1) Anesthesiology. 87(3A): A647, 1997.
and subsequent inflation of a 2F Fogarty catheter in descending thoracic (2) Life Sci. 56(15):285, 1995.
aorta induced 6 min of ischemia under halothane anesthesia. After (3) (4) Anesthesiology. A839,1999.
ischemia rats were randomly divided into four groups and received
intrathecal injections at 30min and 2hrs after reperfusion as follows:
Group-1 saline 10micl and saline 10micl, Group-2 Mor 3micg and
saline 10micl., Group-3 Mor 3micg and Bup 0.2micg, Group-4 Bup
0.2micg and saline 10micl. After injections rats were allowed to
recover, and the motor function was periodically assesed using motor
deficit index (MDI: 6=complete paraplegia, 0=complete normal) for
24hrs.
RESULTS: Neither IT 0.2micg Bup (Group-4) nor IT 3micg Mor
(Group-2) could induce any spasticity same as IT saline (Group-1). On
S-235
APROTININ REDUCES INTERLEUKIN-8 PRODUCTION AND T0) in group B at R1 and onwards. IL-8 and MDA in group B were
LEUKOCYTE INFILTRATION AFTER CEREBRAL significantly higher than the corresponding values in group C and group
ISCHEMIA-REPERFUSION IN A RABBIT MODEL A throughout reperfusion (P < 0.05, or P < 0.01). MDA did not
significantly increase after reperfusion in group A. IL-8 in group A did
AUTHORS: Z. Xia1, R. Xia2, G. Yang2, Z. Xia2, W. Hou2 not significantly increase after reperfusion until R3 (0.80 ± 0.17 ng/L, P
AFFILIATION: 1Centre for Anesthesia & Analgesia, Dept. of < 0.05 vs T0), but was significantly lower than the corresponding value
Pharmacology and Therapeutics, The University of British Columbia, in group B (1.46± 0.23 ng/L, P < 0.05 vs group A). Cerebral cortex
Vancouver, BC, Canada, 2Department of Anesthesiology, Renmin leukocyte infiltration and neuron damage were observed in group B
Hospital, Wuhan University, Wuhan, China. under light microscopy after 30 min ischemia and 4 hours of
reperfusion. These were significantly alleviated in group A.
INTRODUCTION: Clinical and laboratory studies have shown that CONCLUSION: Aprotinin attenuates IL-8 release after complete
aprotinin can reduce interleukin-8 (IL-8) production and leukocyte cerebral ischemia and reperfusion with concomitant reduction in tissue
activation after cardiopulmonary bypass (1,2). It is unknown if leukocyte infiltration and lipid peroxidation. The mechanism is
aprotinin can inhibit interleukin-8 production and brain tissue leukocyte dependent on the anti-protease activity of aprotinin.
infiltration after cerebral ischemia and reperfusion. REFERENCES:
METHODS: Twenty-four New Zealand rabbits were randomly 1.Anesth Analg 1996;83(4):696-700.
assigned into 3 groups (n=8 each). Complete cerebral ischemia was 2.Anaesthesia 1999;54(5):427-33.
induced by the six-vessel model for 30 min followed by reperfusion for
4 hours in group A and B, while group C was sham operated without
occluding the vessels and aprotinin administration. Animals of group A
were given aprotinin at 30,000 KIU/kg through a peripheral vein for a
duration of 10 min before inducing ischemia, followed by 10,000 KIU/
kg per hour throughout the experiment. Animals in group B and C
received the same volume of saline. A catheter was inserted into the
internal jugular bulb for blood samples. Serum concentrations of IL-8
and plasma malondialdehyde (MDA), a marker of lipid peroxidation,
were measured at 15 min (T0) before inducing ischemia, 30 min (R1), 2
hours (R2) and 4 hours (R3) after reperfusion. After the completion of
the experiment, cerebral cortex was obtained and processed with
hematorylin and eosin staining to observe tissue leukocyte infiltration
and neuron damage.
RESULTS: Serum IL-8 (0.48 ± 0.15, 0.39 ± 0.09 and 0.45 ± 0.11 ng/L)
and plasma MDA (4.01 ± 0.21, 3.89 ± 0.83 and 4.12 ± 0.06 nmol/L) did
not differ among group A, B and C at T0. IL-8 and MDA of group C did
not change over time during the experiment. Cerebral ischemia/
reperfusion was associated with significant increase of IL-8 (0.89 ±
0.10 ng/L, P < 0.05 vs T0) and MDA (6.05 ± 0.80 nmol/L, P < 0.01 vs
S-237 2003; 96; S-1–S-293
S-236
NEUROMUSCULAR BLOCK BY INFUSION OF TAAC3 IN THE few seconds; however, prolonged continuous 1Hz stimulation would
PRIMATE bear no semblance to real clinical situation. No changes in blood
pressure and heart rate were detected, either. If results in the primate
AUTHORS: C. Lee1, L. Gyermek1, N. B. Nguyen1, Y. Cho1, S. Tsai2 model bear predictive value, infusion of TAAC3 for limited duration
AFFILIATION: 1Harbor-UCLA Medical Center, Torrance, CA, could be economically feasible and clinically advantageous.
2
Anesthesiology, Veterans General Hospital, Taipei, Taiwan Republic of REFERENCE:
China. (1) Anesth Analg 2002,94:879-85.
TAAC3 is an ultra-short and ultra-fast-acting non-depolarizing

neuromuscular blocking agent currently undergoing pre-human testing
(1). Although it tends to depress blood pressure and cause cardiovagal
block at high doses, it has acceptable pharmacological profile and
superb neuromuscular blocking characteristics. Administration of the
compound by infusion may ameliorate the side effects. However, long
infusion may become uneconomical, and accumulation of metabolites
may prolong the neuromuscular and cardiovagolytic effects. We
evaluated TAAC3 for a 30-minute infusion in monkeys.
METHODS: Monkeys, macaca cyclopis (Swinhoe), 8-12 kg, of either
sex, n = 5, were sedated with ketamine, induced and maintained with
N2O and halothane (0.5%). Respiration was controlled via tracheal
intubation for normocapnia. The ulnar nerve was stimulated (0.1 Hz,
supramaximal, 0.2 ms) and the hypothenar electromyographic response
was quantified. Blood pressure and pulse rate were monitored via
arterial line. Normothermia was maintained. Boluses of TAAC3, i.v.,
was first administered to determine ED80. Twenty minutes later, an 80
% neuromuscular block was rapidly established and maintained for 30
minutes, after which spontaneous recovery was followed to completion.
RESULTS: On single bolus, the recovery index (25-75%) was 0.6
(0.04, SD) min. The ED80 was 0.096 (0.011) mg/kg. The infusion rate
required to maintain an 80 % neuromuscular block was 0.049 (0.003)
mg/kg/min, which did not change during the infusion. The recovery
index after infusion was the same (not measurably different) as that of
pre-infusion bolus. During infusion and after infusion, the blood
pressure and heart rate remained the same as before infusion.
DISCUSSION: Cumulativeness of the neuromuscular blocking effect
of TAAC3, if any, was less than what can be detected in this model. A
faster stimulation rate may detect an increase in the recovery index of a
S-237
PERIPHERAL MUSCARINIC AND NICOTINIC RECEPTORS- up to 6 mg/kg. Thus the peripheral cholinergic blocking side effects -
MEDIATED EFFECTS OF TAAC3, A NEW ULTRASHORT profile of TAAC3 in the rat model seems to be favorable compared to
ACTING MUSCLE RELAXANT IN THE RAT. that of R.
REFERENCES:
AUTHORS: L. Gyermek, C. Lee, N. Nguyen, N. Nguyen, N. Nguyen 1). Brit. J.Anaesth. 54: 147-60, 1982;
AFFILIATION: Harbor UCLA Med. Ctr., Torrance, CA. 2) Pharmacol. Therap. 73: 75-89, 1997;
3) Anesth. Analg .94: 879-85, 2001.
INTRODUCTION: Several side effects of nondepolarizing muscle
relaxants are attributable to their actions on certain muscarinic (m) and
nicotinic (n) Acetylcholine (Ach) receptors (1,2). Therefore TAAC3, a
typical representative of new, ultrashort acting tropinyl diester type
muscle relaxants (3) was studied in rat experiments to explore its
peripheral cholinergic receptor blocking spectrum of action.
METHODS: The following tests were used in anesthetized adult rats:
1) inhibition of the pressor response of the m M1 receptor stimulant,
McN 343-A in spinal rats for the m M1 receptor mediated effect, 2)
inhibition of the bradycardia -response to vagus nerve stimulation for
the m M2 receptor mediated effect, 3)inhibition of the Ach induced
hypotensive response for the m M3 receptor mediated effect, 4)
inhibition of the nicotine -induced pressor responses in spinal rats for
the n receptor mediated effect on sympathetic ganglia 5): inhibition of
the twitch responses (by electromyography) of the anterior tibial muscle
to sciatic nerve stimulation for the n receptors mediated effect on the
neuromuscular junction.ED 50 (SEM) values (N=4-6) were calculated.
Rocuronium (R) was used as a reference standard for comparison.
RESULTS: We found the following inhibitory effects [ED50 (SEM)
mg/kg iv.] of TAAC3 and R against different m and n receptors-
mediated responses: TAAC3: m M1: 1.1 (0.18), m M2: >1.3, m M3: >6,
n (ganglionic): >3, n (neuromuscular): 0.19 (0.009); R: m M1: >3, m
M2: 0.38 (0.015), m M3: >6, n(ganglionic): 0.97 (0.2), n
(neuromuscular): 0.46(0.012).
DISCUSSION: TAAC3, relative to its NMB efficacy showed only
negligible blocking effects on peripheral m and ganglionic n receptors-
mediated functional responses. R. was less potent in blocking the m M1
receptors mediated effect than TAAC3. Hovewer, its was more potent in
blocking the m M2 and n (ganglionic) receptors -mediated effects than
TAAC3. Neither agents blocked the m M3 receptor mediated responses
2003; 96; S-1–S-293 S-239
S-238
EFFECTS OF PHENYTOIN ON ROCURONIUM-INDUCED shifted to the right significantly in PP4W group compared with control,
NEUROMUSCULAR BLOCKADE ON RAT HEMI- PP1D and PP1W (P < 0.05).
DIAPHRAGM PREPARATION CONCLUSION: The potency of rocuronium will be increased in the
acute exposure to the high dose of pheyntoin. However chronic
AUTHORS: H. Yang, Y. Lee, J. Kim, S. Han anticonvulsant therapy will be antagonized the action of rocuronium.
AFFILIATION: Asan Medical Center, College of Medicine, REFERENCE
University of Ulsan, Seoul, Republic of Korea. 1. J Neurosurg Anesthesiol 2001; 13: 79-82.
2. Anesthesiology 1999; 90: 1551-5.
INTRODUCTION: Chronic anticonvulsant therapy with phenytoin
antagonizes the action of nondepolarizing muscle relaxants. Effective Dose of 5, 50, 90, 95% of rocuronium in non-treated and pretreated group
Rocuronium is a new non depolarizing muscle relaxant of rapid onset (Mean ± S.D.)
and intermediate duration of action. This study was designed to Control
investigate the effects of phenytoin on rocuronium-induced group
Phenytoin non-treated group Phenytoin pretreated group
neuromuscular blockade on the hemidiaphragm preperation.
1 g/ml 10 g/ml 100 g/ml 1 day 1 week 4 weeks
MOTHODS: Male Sprague-Dawley rats (150-250g, n=70) were
randomly allocated into control group (C, n=10), three phenytoin-non- 212.2 ± 245.7 ± 121.3 ± 252.9 ± 183.8 ± 353.7 ±
ED5 (g) 250.6 ± 81.8
pretreated group (PNP) and three phenytoin-pretreated group (PP). In 75.8 70.1 26.3* 67.5 113.7 82.0†
phenytoin-pretreated group, phenytoin 50 mg/kg/day was administered ED50 (g) 492.7 ± 81.8
432.7 ± 396.2 ± 179.0 ± 476.7 ± 423.8 ± 640.0 ±
intraperitoneally once a day for one day (PP1D, n=10), one week (PP1W, 75.8 70.1 26.3* 67.5 113.7 82.0†
n=10) and four weeks (PP4W, n=10). Animals were anesthetized with 40 604.5 ± 513.5 ± 223.9 ± 651.0 ± 610.8 ± 863.0 ±
ED90 (g) 681.3 ± 81.8
mg/kg of thiopental sodium intraperitoneally and the hemidiaphragm 75.8 70.1 26.3* 67.5 113.7 82.0†
with phrenic nerve was dissected and mounted in a bath containing 100 653.2 ± 546.7 ± 236.7 ± 700.4 ± 663.8 ± 926.3 ±
ml of oxygenated Krebs' solution at 32°C. The phrenic nerve was ED95 (g) 734.7 ± 81.8
75.8 70.1 26.3* 67.5 113.7 82.0†
stimulated at the supramaximal intensity by stimulator through isolation
unit and twitch responses were measured by precalibrated force
displacement transducer and recorded. After stabilization of twitch
response, rocuronium was added to the solution to obtain an initial
concentration of 100 g. When a stable 3-5 twitch was obtained after the
first dose, the concentration of rocuronium was increased in increments
of 50 g to obtain more than 95% neuromuscular twitch inhibition at 0.1
Hz. In pheytoin-non-pretreated group,phenytoin 1 g/ml (PNP1, n=10),
10 g/ml (PNP10, n=10), 100 g/ml (PNP100, n=10) were administered with
initial dose of rocuronium simultaneously. Data were analyzed by
probit and logistic models.
RESULTS: The dose-response curve of rocuronium was significantly
shifted to the left in PNP100 group compared with control, PNP1 and
PNP10 group (P < 0.05). The dose-response curve of rocuronium was
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CISATRACURIUM, BUT NOT MIVACURIUM, DECREASES up by morphological studies investigating the site of damage (e.g.
SURVIVAL OF RAT SYMPATHETIC NEURONS IN VITRO growth cone).
REFERENCES:
AUTHORS: P. Lirk1, L. Klimaschewski2, S. Longato2, J. Rieder1 (1) The influence of atracurium, cisatracurium, and mivacurium on the
AFFILIATION: 1Dept. of Anesthesiology and Critical Care Medicine, proliferation of two human cell lines in vitro. Anesth Analg
Innsbruck, Austria, 2Dept. of Anatomy, Histology and Embryology, 2001;93:690-6.
Innsbruck, Austria. (2) Does ester hydrolysis change the in vitro degradation rate of
cisatracurium and atracurium? Br J Anaesth. 2002 Apr;88(4):555-62.
INTRODUCTION: Cis-atracurium is a widely used neuromuscular (3) Multiple channel interactions explain the protection of sympathetic
blocking agent. Previous reports have indicated growth-inhibitory neurons from apoptosis induced by nerve growth factor deprivation. J
effects of isoforms cis-atracurium and atracurium on two human cell Neurosci. 2002 Jan 1;22(1):114-22.
lines (Human umbilical vein endothelial cells and Human hepatoma G2
cells) in vitro (1). These effects were ascribed to oxidative stress elicited
by acrylate esters formed during cis-atracurium breakdown via the
Hofmann reaction (2). Mivacurium, not decomposed via the Hofmann
reaction, did not impair growth. Rat sympathetic neuronal cells have
been established as an in vitro model for neuronal survival (3).
Therefore, the aim of the present study was to investigate the effects of
cisatracurium upon neuronal cells. The hypothesis was that
cisatracurium would not impair cellular survival.
METHODS: Sympathetic neuronal cells were excised from newborn
rats and cultured in Roswell Park Memorial Institute (RPMI) medium
plus Nerve growth factor (NGF, 1:000) on a poly-d-lysine-coated
surface for three days. Following medium and NGF replacement, cells
were incubated for 24 hours with cis-atracurium and mivacurium at
concentrations of 0 (control), 1, 2, 5, and 10 mM dissolved in RPMI.
All cell counts before and after incubation in each well were attained by
the same author who was blinded to the incubation pattern.
RESULTS: A dose-dependent decrease in neuronal cell survival was
caused by cisatracurium at concentrations of 5 and 10 mM
cisatracurium, whereas mivacurium did not elicit a significant decrease
in cell survival as compared to controls.
DISCUSSION: The dose-dependent decrease in cellular survival in the
present study indicates the possibility of neuronal damage upon
prolonged exposure to cisatracurium, as e.g. during long-term
relaxation. This effect was observed at doses exceeding those achieved
in clinical settings. Results from the present study should be followed
S-241 2003; 96; S-1–S-293
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INTERACTIONS OF EDROPHONIUM WITH NEOSTIGMINE was attenuated by edrophonium at doses of 100 microM or greater, and
IN THE RAT TRACHEA was 0.02 ± 0.09 g at a dose of 300 microM. This attenuation was
reversed to 87% of control levels by washing with fresh K-H solution.
AUTHORS: O. Shibata, M. Saito, M. Yoshimura, M. Yamaguchi, T. Neostigmine-induced IP1 accumulation of rat tracheal slices was
Makita, K. Sumikawa attenuated by edrophonium at a dose of 100 microM, and this
AFFILIATION: Nagasaki University Hospital, Nagasaki, Japan. attenuation was reversed by washing with fresh K-H solution.
Decreases in IP1 accumulation at large doses were consistent with
INTRODUCTION: The muscarinic M3 receptor has both an relaxation of rat tracheal rings.
orthosteric-binding site and an allosteric-binding site. Neostigmine at CONCLUSION: Edrophonium at large doses would bind the allosteric
smaller doses would bind strongly to the orthosteric site of M3 site of M3 muscarinic receptors, resulting in the inhibition of the action
muscarinic receptors, resulting in tracheal smooth muscle contraction of the orthosteric site of M3 muscarinic receptors.
through the activation of PI response (1). Neostigmine at larger doses REFERENCES:
would bind to the allosteric site, which inhibits the action of the 1. Anesth Analg 92:100-105, 2001.
orthosteric site of M3 muscarinic receptors, resulting in the attenuation 2. Can J Anaesth 45:1190-1195, 1998.
of contraction through the inhibition of PI response (1). Although 3. Anesth Analg 82:1211-1214, 1996.
edrophonium itself does not affect the resting tension and PI responses
of rat trachea (1-3), it at larger doses may bind to the allosteric site,
resulting in the inhibition of the action of the orthosteric site of M3
muscarinic receptors. Thus, we examined the effects of edrophonium on
neostigmine –induced contractile and PI responses of rat trachea.
METHODS: The studies were conducted under guidelines approved
by the Animal Care Committee. Thirty Wistar rats (250-350 g) were
used. The rats were anesthetized with pentobarbital, and the tracheas
were rapidly isolated. The trachea was cut into 3-mm-wide ring
segments or 1-mm-wide slices. Neostigmine (100 microM in final
concentration) was added, and ring tension was examined by additions
of edrophonium from 0 microM to 1000 microM in final
concentrations. After the completion of the experiment, Krebs-
Henseleit (K-H) solution containing both edrophonium and neostigmine
(in the organ chamber) was changed three times with fresh K-H solution
and the tension was recorded. Tracheal slices were incubated with
[3H]myo-inositol and 100 microM neostigmine in the presence or
absence of edrophonium. The [3H] inositol monophosphate (IP1), a
degradation product of PI response, was measured with a liquid
scintillation counter. Data were expressed as mean ± SE. Statistical
significance (P < 0.05) was determined using ANOVA.
RESULTS: Neostigmine-induced tension was 2.02 ± 0.21 g, which
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CHOLINESTERASE DEFICENCY: IDENTIFICATION OF A and and not present in a control sample.
NOVEL MUTATION DISCUSSION: Two mutations in the BCHE gene were detected in two
patients with clinical and biochemical reduced BCHE activity. Mutation
AUTHORS: T. Girard, H. Ginz, E. Voronkov, E. Buehler, A. Urwyler C551T has been described (2), mutation G1294T has not yet been
AFFILIATION: Departments of Anesthesia and Research, University published. In the latter a premature stop codon leads to a shorter protein
of Basel, Switzerland. and may explain the reduced BCHE activity. Our findings confirm the
heterogenetic nature of reduced BCHE activity. If BCHE deficiency can
INTRODUCTION: A reduction of atypical cholinesterase be linked to certain mutations, then genetic investigations may in future
(Butyrylcholinesterase = BCHE) activity leads to a prolonged duration be helpful in identifying those individuals and thus increase
of action of drugs metabolized by this enzyme, such as succinylcholine perioperative patient safety.
and mivacurium. As day-case surgery is becoming more frequent, short REFERENCES:
acting muscle relaxants - such as mivacurium - are increasingly 1. Anesth Analg 77:380-6;1993.
important. A delay in inactivation of these drugs can lead to prolonged 2. Anesth Analg 81(2):419-21;1995.
mechanical ventilation, which is not only unpleasant and potentially
harmful for the patient but also increases health care costs. BCHE
activity is biochemically determined and individuals are diagnosed as
homo- or heterozygous on the basis of total activity, dibucain- and
fluoride-inhibition. Recent molecular genetic investigations have
proven this biochemical classification to be imprecise and frequently
incorrect (1). We have therefore genotyped two patients with clinically
prolonged duration of action of succinylcholine by investigating the
DNA sequence of BCHE. The gene for BCHE is located on
chromosome 3q26. The coding sequence is 1722 base pairs long and
encodes for a polypeptide of 574 amino acids.
METHODS: Two patients with a history of prolonged neuromuscular
block following succinylcholine and a biochemically determined BCHE
activity of <50% were investigated. Blood samples were taken for DNA
isolation. Primers for polymerase chain reaction (PCR) were designed
to flank all 4 exons. A randomly selected DNA sample was used as
control. PCR products were commercially sequenced and the resulting
sequences compared with the sequence in the human genome database
(http://www.ncbi.nlm.nih.gov/). If polymorphisms were identified, then
they were confirmed by sequencing in the reverse direction.
RESULTS: We found a mutation in each of the two patients. The first
mutations was a C -> T at position 551, resulting in a valine for alanine
substitution, the second mutation was a G -> T at position 1294,
resulting in a premature stop codon. Both mutations were heterozygous
2003; 96; S-1–S-293 S-243
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NATRIURESIS GOVERNS THE DURATION OF THE excretion was considered. This volume expansion decayed at an
EXTRACELLULAR VOLUME EXPANSION AFTER INFUSION average rate of 20% per hour which, however, varied greatly in the
OF HYPERTONIC SALINE IN SHEEP animals, depending on their capacity to excrete sodium. Computer
simulations indicated that a tripled natriuresis (up to approx. 750 mmol/
AUTHORS: R. G. Hahn1, K. S. Waldrop2, L. Edsberg3, C. H. Svensén2 L) would almost double the rate of elimination.
AFFILIATION: 1Karolinska institute at Soder Hospital, Stockholm, CONCLUSION: The sodium excretion was inversely proportional to
Sweden, 2Department of Anesthesiology, Galveston, TX, 3Department the duration of the ECF volume expansion by 7.5% saline.
of Numerical Analysis, Stockholm, Sweden.
BACKGROUND: The mechanisms governing the duration of the
extracellular fluid volume (ECF) expansion due to intravenous infusion
of hypertonic saline solution are poorly understood. We hypothesized
that the duration is closely related to the sodium excretion.
METHODS: Six conscious splenectomized ewes with a mean body
weight of 30 kg were given an intravenous infusion of 4 mL kg-1 of
7.5% saline solution on two occasions, one over a period of 5 min and
another over 20 min. Mass balance and volume kinetic calculations of
the distribution and elimination of fluid were performed after repeated
sampling of the plasma sodium concentration and the urinary excretion
of water and sodium during 3 hours. The translocation of water from the
cells to the ECF space was calculated based on the added osmolality,
and the backward shift during the follow-up from the relationship
between serum sodium and urinary sodium concentrations.
RESULTS: The amount of fluid infused was 119 ± 8 mL, and the fluid
volume translocated from the intracellular space due to osmosis
amounted to 564 ± 9 mL. Urinary excretion amounted to 228 ± 46 mL
(mean ± SEM). The urinary sodium concentration increased gradually
and exceeded the plasma sodium after 30 min. From this time onward,
the sodium excretion produced a net uptake of fluid into the
intracellular space, which finally amounted to 95 ± 30 mL. There were
virtually no differences in these results between the groups. For the
entire experiment, there were strong linear correlations between urinary
excretion of fluid and sodium and the calculated uptake of fluid to the
cells (see Figure).
The hypertonic saline increased the serum sodium level by 8%, which
corresponded to a 10% dilution of the ECF space. Subsequent
reductions of the ECF expansion could be estimated only if the sodium
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ROLE OF NALOXONE AND AUTOLOGOUS BLOOD REFERENCES:
TRANSFUSION ON THE RECOVERY FROM HEMORRHAGIC 1. Henderson LA, Keay KA, Bandler R. Neuroreport. 2002 Apr
SHOCK IN DOGS 16;13(5):729-33.
AUTHORS: R. Michael1, M. M. Sabry2, K. Govindan1, A. R. Abadir1

AFFILIATION: 1The Brookdale University Hospital and Medical
Center, Brooklyn, NY, 2Faculty of Medicine- Cairo University, Cairo,
Egypt.
INTRODUCTION: Opioid peptides, such as endorphins and
enkephalins have been found in brain, peripheral tissues, blood, and
were associated with the mediation of pain perception. They produce
hypotension and the plasma levels of B- endorphin rise during stress
(1). In the present work the possible inclusion of endogenous peptides
in hemorrhagic shock and the possible reversal of the state of shock by
injection of the morphine antagonist naloxone were investigated.
METHODS: Hemorrhagic shock was induced and maintained for 30
min. in dogs. In the control group (GI, 8 dogs) animals received only
autologous blood transfusion. In another group of the experiment, (GII,
8 dogs), naloxone (1 mg/kg) was given immediately before autologous
blood transfusion. The various cardiovascular parameters were
recorded pre and post infusion of autologous blood transfusion
RESULTS: In GI, hemorrhage resulted in a highly significant drop in
systolic, diastolic and pulse pressure, while the heart rate significantly
increased. These average values were maintained for 30 min., during
which two dogs died. With autologous blood transfusion the living
animals recovered after 5 min. and gradually the heart rate returned to
normal after 30 minutes, while the systolic, diastolic and pulse pressure
returned to normal after 45 min. In GII, The systolic, diastolic and pulse
pressure as well as the heart rate returned to the normal levels within 5
min.
CONCLUSION: These findings do not only indicate the possible role
of morphine in post-operative shock but it may have the clinical
implication of the role of naloxone in the management of hemorrhagic
shock
S-245 2003; 96; S-1–S-293
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THE CHAOTIC ANALYSIS OF EEG CAN REFLECT DEPTH fractal dimensions showed the non-integers between 2 and 8. The
OF ANESTHESIA. maximum Lyapunov index was positive and other Lyapunovs‘ were
near 0. These results suggest that the EEG shows the chaotic
AUTHORS: I. Uchida1, M. Amata1, Y. Maniwa2 characteristics both with and without anesthesia. The TPM values
AFFILIATION: 1Osaka University Medical School, Osaka, Japan, depicted 0.4 to 0.5 in awake and 0.2 to 0.3 during anesthesia, they
2
Oya Research Institute of Advance Health Science, Hyogo, Japan. shifted during anesthesia with the BIS level.
CONCLUSIONS: The EEGs can be the deterministic chaos and
Measuring depth of anesthesia has been an enigma ever since general especially the TPM values may reflect the anesthetic depth.
anesthesia was clinically introduced 150 years ago. The most widely
evaluated tool for assessing depth of anesthesia has been the
electroencephalograph (EEG). The bispectral index (BIS), a value
derived from the EEG, has been recently developed to measure
anesthetic effects and has been rapidly accepted for clinical use in
anesthesia. However, BIS monitoring can effectively reflect the
hypnotic component of anesthesia but fail to respond to the analgesic
component. This disadvantage of the BIS may arise from the limitations
of linear science analysis such as frequency analysis, upon which BIS
analysis is primarily based The EEG is a bio-signal from the complex
systems and can be subject to rules of Chaos. Chaos theory is a typical
mathematical theory for non-linear science and yields deterministic
rules for signals. Using the chaotic theory, we analyzed the EEGs of the
patients during anesthesia and compared them with the BIS.
METHODS: The EEGs were collected from the patients receiving
sevoflurane-fentanil-N2O anesthesia. The EEG signal was acquired
using Aspect A-1000 EEG monitor and Neuropack 8 monitor through
the leads of Fp1 with CZ as the reference. Digitized raw EEG (sampling
rate: 16 to 50 kHz, band pass: 0.1-850 Hz) was recorded into the
personal computer and used for the chaotic analysis with off-line. As
the chaotic parameters, the fractal dimension, Lyapunov index and
trajectory parallel measurement (TPM) were analyzed for the EEGs
during anesthesia The optimum embedding parameters for the EEG
chaos analysis were determined by the local fuzzy reconstruction
methods. All chaotic analyses were performed by the chaos analysis
software, “meiChaos“ (Meidensha Corp.).
RESULTS: For the EEG chaos analysis, the optimum embedding
parameters were 3 for the detention, 2 for the delay and 9 for the
neighborhood before, during and after anesthesia. The values of the
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REGIONAL CBF IS DECREASED IN DIFFERENT REGIONS 91.1 + 6.1, PROhi 68.7 + 5.6, THPmed : 89.7 + 4.4, THPhi 75.3 + 5.3;
OF THE BRAIN BY PROPOFOL AND THIOPENTAL AT n.s. between groups). RT increased similarly in both groups (THPbase
EQUAL DRUG EFFECT 258 + 70 THPmed 398 + 101, PRObase 213 + 54 PROmed 325 + 95
msec, no RT in high dose; n.s. between groups). The pattern of rCBF
AUTHORS: R. Veselis1, V. Feshchenko2, R. Reinsel2, A. decreases was different for propofol and thiopental (see Figure).
Lalmansingh2, B. Beattie2, T. Akhurst3
AFFILIATION: 1Memorial Sloan Kettering Cancer Center ; Weill
Medical College at Cornell University, New york, NY, 2Memorial Sloan
Kettering Cancer Center, New York, NY, 3Memorial Sloan Kettering
Cancer Center ; Weill Medical College at Cornell University, New
York, NY.
INTRODUCTION: Thiopental and propofol produce similar sedative
effects, but propofol has a greater amnesic effect (1). Changes in
regional cerebral blood flow (rCBF) induced by a drug may indicate the
neuroanatomical location of drug effect, thus helping understand the
mechanism of drug action (2). This study was undertaken to identify
brain regions affected by propofol (PRO) different from those of the
sedative control drug thiopental (THP) given at equivalent medium and
high sedative concentrations. Significant decreases in rCBF were
identified using SPM99 analysis of CBF images obtained using positron SPM interaction analysis showed that propofol produced more effects in
emission tomography with O-15 water (O-15 PET). the frontal, orbito-frontal and temporal regions, located in the superior
METHODS: Following informed consent, 8 right- handed male and medial frontal gyri (Brodmann‘s Area (BA) 8,9,10), the rectal gyrus
volunteer subjects (age 32.3 + 11.5 yrs, weight 72.4 + 7.7 kg) were (BA 11) and middle temporal gyrus (BA 37,39).
randomized to receive THP (n=4) or PRO (n=4) using Stanpump CONCLUSIONS: At equivalent levels of sedation propofol and
software (S. Shafer; http://anesthesia.stanford.edu/pkpd) to target thiopental affect different regions of the brain. Regions of the brain
medium (THP 4 and PRO 1.2 ug/ml) and high (THP 7-9 and PRO 2.5-3 affected by propofol compared with thiopental may help identify the
ug/ml) sedative concentrations. The high concentration was associated loci of the non-sedative effects of propofol, such as amnesia.
with unresponsiveness to voice. Bispectral Index was monitored using a REFERENCES:
standard clinical electrode montage (Ziprep Electrodes, Aspect 1050 (1) Veselis RA, Reinsel, R. A. Feshchenko, V. A. Wronski, M.: The
monitor, Aspect Medical Systems, Natick, MA). Four CBF images were comparative amnestic effects of midazolam, propofol, thiopental, and
obtained during resting, auditory and tactile stimuli in baseline, medium fentanyl at equisedative concentrations. Anesthesiology 1997; 87: 749-
and high drug conditions (total of 12 scans; 10 mCi radiotracer/scan). 64
Between scans responsive subjects performed a reaction time task (2) Veselis RA, Reinsel RA, Feshchenko VA, Dnistrian AM: A
pushing a button upon hearing a tone. Decreases in rCBF were neuroanatomical construct for the amnesic effects of propofol.
considered significant at a voxel-level p<0.001 (uncorrected). Anesthesiology 2002; 97: 329-37
RESULTS: BIS values decreased similarly in both groups (PROmed : Funding from NIH R01-58782, Bethesda, MD.
2003; 96; S-1–S-293 S-247
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CALORIMETRIC MEASUREMENTS OF BINDING OF DISCUSSION: The results demonstrate that binding of volatile agents
VOLATILE ANESTHETICS TO SERUM ALBUMIN is driven by enthalpic changes that must involve close contact with
binding site(s) in proteins. Selectivity for drugs is primarily entropic.
AUTHORS: A. Sawas, M. Rebecchi, S. Pentyala Beyond the obvious chemical and stereochemical differences, the only
AFFILIATION: State University of New York, Stony Brook, NY. general physical property that correlates with binding free energy is the
lipole movement, R2 = 0.52 and 0.90 for high and low affinity binding
INTRODUCTION: Close correlation exists between oil/gas partition respectively. This correlation suggests that the distributed lipophilicity
coefficients and potencies of general anesthetics. While this relation of the drugs best explain their binding. The differences in excess heat
suggests that sites of action are hydrophobic, it does not imply that the capacity changes suggest a molecular selectivity with respect to protein
binding is driven by hydrophobic interactions. On contrary, this simple conformation. Binding of anesthetics seems to produce specific changes
correlation implies that, partitioning is enthalpy driven that require in conformation, probably involving constraints to main chain
close contacts with the binding site(s). This study examines the binding movements, resulting in less overall contact with water. These changes
of closely related haloethers (desflurane, isoflurane, enflurane, could well involve a further shielding of hydrophobic side chains form
sevoflurane), a haloalkane (halothane), and an intravenous anesthetic solvent water; consistent with earlier reports of increased protein
(propofol) to bovine serum albumin. stability and excess heat capacity changes associated with binding of
METHODS: Heat produced or absorbed on binding of drugs to halothane to albumin (2).
albumin was measured by isothermal titration calorimeter. Haloether REFERENCES:
data was fit to high and low affinity binding site (N=3) model, 1.Journal of Biological Chemistry. 275: 38731-38738, 2000.
haloalkane data to a sequential model and propofol data to a single high 2.Toxicology Letters. 100-101: 387-391, 1998.
affinity site model. Using standard nonlinear least squares regression
models, number of drug molecules bound per macromolecule (N),
equilibrium association constant (Ka), as well as the enthalpy and
entropy of binding were determined.
RESULTS: The affinities (Ka) of the volatile agents were in the order:
desflurane > isoflurane > enflurane> halothane > sevoflurane.
Competition studies indicated that anesthetics bind to the same high
affinity site. We believe this represents the propofol/halothane binding
lipophilic site (IIIA) identified on albumin (1). Interestingly, these
binding constants were positively correlated (R2 = 0.86) with anesthetic
potency (EC50). All drugs produced significant heat generation with
similar binding enthalpies of - 4600 to - 7600 cal/mol. The effects of
temperature on enthalpy were evaluated in the range of 15o to 25oC. In
all cases, except isoflurane, increasing temperature increased the
enthalpic contribution to binding. The results demonstrated a large
excess negative dCp for all volatile agents (except for isoflurane),
ranging from -1180 to -72 cal/mol/degree.
S-247
TEMPERATURE DEPENDENCE OF SOLUBILITY OF DISCUSSION: Sevoflurane is less sensitive to temperature than either
HALOTHANE, ISOFLURANE AND SEVOFLURANE halothane or isoflurane. Krebs/O2 was isoflurane > halothane, whereas
tissue solubility was halothane > isoflurane . This is the first report of
AUTHORS: D. Breukelmann, J. J. Nesbitt, P. R. Housmans Ostwald solubility coefficients (Krebs/O2) of H, I and S collected in
AFFILIATION: Mayo Foundation, Rochester, MN. identical conditions with rigid control of pressure and temperature. The
values are lower than those reported separately for individual
INTRODUCTION: In vitro experiments with volatile anesthetics are anesthetics in various aqueous media. The temperature dependence is
often performed at temperatures other than encountered in vivo. There similar to that reported for tissue/gas solubilities . Support: USPHS
is very little data on the temperature dependence of the solubility of GM36365, Mayo Foundation, IMF Muenster, Deutsche
modern volatile anesthetics.We have therefore examined the effects of Forschungsgemeinschaft.
temperature on the solubility of halothane (H), isoflurane (I) and REFERENCES:
sevoflurane (S) in a physiologic salt solution. 1. Br J Anaesth, 1973; 45: 294-300.
METHODS: A modified Krebs solution (200 ml of Na+ 137.5 mM, K+ 2. Anesth Analg, 2001; 93: 234-8.
5, Mg2+ 1, Ca2+ 2, Cl- 124.5, SO42- 1, acetate 20, MOPS 5, glucose 10, 3. Anesthesiology, 1972; 37: 87-91.
pH 7.4) was vigorously (>1000 ml/min) bubbled with 100% O2 and 4. J Pharm Biomed Anal, 1992; 10: 1-7.
anesthetic vapor (0.8% and 1.6% for H and I; 1% and 2% for 5. Anesthesiology, 1977; 47: 62-3.
sevoflurane) in a temperature-controlled water-jacketed glass chamber 6. Anesthesia & Analgesia, 1987; 66: 654-6.
residing in a closed Lucite box at ambient pressure. Care was taken to
avoid pressure and temperature changes in gas and liquid phases.
Anesthetic gas concentration was measured continuously at different
positions in the gas phase in the glass chamber (Ohmeda 5330 Agent
Monitor). Anesthetic concentrations in the liquid phase were measured
by gas chromatography (Hewlett Packard 5880A) after 30 and 60 min
equilibration at each temperature. The Ostwald solubility coefficients =
Cliq * R * Tk/ [(pamb-paqua)* Cgas * 10] were calculated for data at 15ºC,
20ºC, 25ºC, 30ºC and 37ºC (n > 34 measurements for each anesthetic
and temperature). From all data points of each anesthetic, the
relationship between and temperature was fitted to the equation = 37 *
[1 + (k/100)] T to yield the temperature coefficient k and 37 ( at 37ºC).
RESULTS: Liquid and gas temperatures were the same for each data
set. Krebs/O2 solubility coefficients at 37ºC were 0.33 (H), 0.48 (I),
0.19 (S) with temperature coefficients of -0.0491 (H), -0.0426 (I), -
0.038 (S). Decreasing temperature increased more for halothane and
isoflurane than for sevoflurane. There was no difference between
measurements taken after 30 or 60 min of equilibration.
S-249 2003; 96; S-1–S-293
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THE EFFECTS OF DIFFERENT ANESTHETIC AGENTS ON significance for fentanyl and ketamine (4.6 and 3.4 times control).
METASTATIC DEVELOPMENT AND NATURAL-KILLER
CELL ACTIVITY: A COMPARATIVE STUDY IN RATS
AUTHORS: S. Bar-Yosef1, R. Melamed2, G. Shakhar2, K. David2, S.
Ben-Eliyahu2
AFFILIATION: 1Department of Anesthesiology, Duke University
Medical Center, Durham, NC, 2Psychobiology Research Unit,
Department of Psychology, Tel-Aviv University, Tel-Aviv, Israel.
INTRODUCTION: Immunosuppression following surgery is partly
ascribed to the effects of anesthesia, and may compromise patients’
resistance to infection and metastasis. These effects may be mediated in
part by suppression of natural killer (NK) cells – a subset of
lymphocytes with special importance in host resistance against
malignant and virally infected cells. The current study compares the
effects of various anesthetic agents on the susceptibility to metastasis
and on NK cell function.
METHODS: Fischer-344 rats (N=81) remained undisturbed in their
home cages (Control), or were kept anesthetized for one hour using
either inhaled halothane (via vaporizer) or one of the following Fentanyl, halothane, ketamine, and thiopental decreased NK cytotoxic
intravenous anesthetics: Thiopental, Ketamine, Propofol, or Fentanyl. activity to 15%, 25%, 25%, and 33% of control levels, respectively.
All anesthetics were given by titration to animal movement and Propofol anesthesia was associated with a non-significant decrease in
respiration rate. Three hours later, blood was drawn for the assessment activity.
of NK-cell cytotoxic activity using 51Cr release assay and the assesment The number of circulating NK cells in the blood was significantly
of NK cell number using fluorescence-activated cell sorter (FACS) decreased by halothane (by 34% from the baseline), ketamine (36%)
analysis. Concomitantly, the rats were inoculated intravenously with and thiopental (58%), but not by propofol. The effect of fentanyl was
radiolabeled MADB106 mammary adenocarcinoma cells that not assessed.
metastasize only to the lungs. Twenty hours later, lungs were removed DISCUSSION: In the current study, most anesthetic agents, both
and their radioactivity measured to indicate lung tumor retention (LTR). volatile (halothane) and i.v. agents (thiopental, ketamine, fentanyl)
Groups were compared using ANOVA, with Bonferroni post-hoc test increased the susceptibility to metastatic development and
used for pairwise comparisons. As a measure of cytotoxic activity, the concomitantly suppressed NK-cell cytotoxic activity in the blood, partly
number of lytic units (defined as 100 divided by the effector-to-target by reducing the number of circulating NK cells. Propofol did not affect
cell ratio required to lyse 20% of the target cells) was calculated from these immunological indices, favoring its use in cancer patients
the cytotoxic assay curves using regression exponential fit method. undergoing surgical procedures. We suggest that immunological aspects
RESULTS: All anesthetic agents except propofol caused an increase in should be considered when choosing an anesthetic.
LTR compared to the control group (Figure), reaching statistical
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SITE OF ACTION OF TIME-DEPENDENT INHIBITION BY REFERENCES:
LOCAL ANESTHETICS [1] Hollmann MW et al. Anesthesiology 2000; 93:A828, [2] Herroeder S et
al. Eur J Anaesthesiol 18:78
AUTHORS: S. Herroeder1, C. G. den Bakker2, M. A. Marcus2, E.
Martin1, M. E. Durieux2, M. W. Hollmann1
AFFILIATION: 1Dept. of Anesthesiology, Heidelberg, Germany,
2
Dept. of Anesthesiology, Maastricht, Netherlands.
INTRODUCTION: Local anesthetics (LA) were shown to inhibit the
signaling of G protein-coupled receptors (GPCRs) in Xenopus oocytes and
human neutrophils (hPMNs) time-dependently [1,2]. This study aimed to
characterize the possible site of action of this time-dependency in more
detail.
METHODS: To define the site of action more specific, the effects of
extracellularly applied (5mM) and intracellularly injected (42µM, 1/10 of IC
50) QX 314, a membrane-impermeable lidocaine-analog, on control- and
Gq-depleted (DNA antisense-knock down) Xenopus oocytes were studied.
Therefore endogenous lysophosphatidic acid (LPA) receptors were
stimulated (0.6 µM (EC50)) and Ca2+-activated Cl--currents (ICl(Ca) ) were
measured at different time points (10min - 48h) after LA-application, using
2-electrode-voltage-clamp-technique. Data are normalized to
corresponding control responses and shown as mean±sd (n>22).
RESULTS: LPA-signaling in Xenopus oocytes was inhibited by
intracellularly injected QX314 in a time-dependent manner (reduction to
40±7 % of control response after 24h), whereas no effects were observed
when the LA was applied extracellularly or in the absence of the Gq
protein. In contrast lidocaine attenuated LPA-signaling in Gq depletd
oocytes significantly to 75 % of control, when applied extracellularly, but
not time-dependently.
DISCUSSION: Our study shows that one possible site of action of the the
time-dependent effect of GPCR-signaling inhibition by LA is located
intracellular and critically dependent on Gq protein function. The non-time-
dependent inhibition of LPA-signaling by lidocaine is explainable by an
additional extracellular located binding site for LA. Thus, clinically
relevant effects, based on GPCR signaling (e.g priming of hPMNs), might
be attenuated more potent by continuous application of LA.
2003; 96; S-1–S-293 S-251
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MECHANISMS OF TIME-DEPENDENT INHIBITION BY any influence on time-dependent inhibition by LA. As agonist-
LOCAL ANESTHETICS independent stimulation of the G protein is inhibited by LA time-
dependently as well, the underlying mechanism and the site of action
AUTHORS: S. Herroeder1, N. G. Berkelmanns2, D. Struemper2, E. seem to be located downstream of the G protein activation and
Martin1, M. E. Durieux2, M. W. Hollmann1 independent from GDP/GTP-exchange.
AFFILIATION: 1Dept. of Anesthesiology, Heidelberg, Germany, REFERENCES:
2
Dept. of Anesthesiology, Maastricht, Netherlands. [1] Hollmann MW et al. Anesthesiology 2000; 93:A828
INTRODUCTION: Local anesthetics (LA) were shown to inhibit the

signaling of G protein-coupled receptors (GPCRs) in a time-dependent
manner [1]. The underlying mechanisms are not cleared in detail yet.
We therefore studied to what extent this time-dependent effect of LA is
affected by inhibition of various proteins within the signaling pathway
and agonist independent stimulation of the G protein.
METHODS: Xenopus oocytes were incubated in either proteinkinase c
(PKC)-antagonists (CT or BIM, 10 µM) or a phospatase inhibitor
(okadaic acid, 1 µM), followed by application of bupivacaine (450 µM
(1/10 of IC50)). Ca2+-activated Cl--currents (ICl(Ca) ), induced by
lysophosphatidic acid (LPA, 0.6 µM) or agonist-independent, using
guanosine-5’-O-3-thiotriphosphate (GTPS, 1 mM) or aluminumfluoride
(AlF, 100 µM), were measured at different time points (10min - 48h)
after LA application, using 2-electrode-voltage-clamp-technique. Data
are normalized to corresponding control responses and shown as
mean±sd (n>22).
RESULTS: Inhibition of PKC enhanced LPA-signaling to 40 % and 20
% of control for CT and BIM, respectively, wheras the use of okadaic
acid attenuated LPA induced responses to 70 % of control. In contrast
neither inhibition of PKC nor phosphatase-activity affected the time
dependent effect of bupivacaine on LPA signaling at all (13±3 % , 20±5
%, 11±4 % and 9±4 % of control for bupivacaine and in the presence of
CT, BIM and okadaic acid, respectively, after 8 h). Similar results were
obtained for GTPS and AlF induced ICl(Ca), namely a time-dependent
inhibition by bupivacaine to 29±10 % and 17±8 % of control after 4h of
incubation.
DISCUSSION: LPA-signaling is based on a sensitive balance between
phosphorylation and dephosphorylation. Modulation of one side or the
other enhances or attenuates the signaling cascade but does not have
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DIFFERENTIAL INHIBITION OF CYCLIC NUCLEOTIDE- lipid solubilities. Dyclonine, a ketone local anesthetic, was the most
GATED CHANNELS BY LOCAL ANESTHETICS potent inhibitor. Dyclonine is used exclusively for topical anesthesia.
When compared with lidocaine for airway anesthesia, dyclonine
AUTHORS: A. L. Landrum, G. L. McKinney, B. M. Tilghman, G. R. produces a longer lasting and more intense topical anesthesia4 .
Kracke Lidocaine, an amide local anesthetic, was the least potent inhibitor of
AFFILIATION: University of Missouri-Columbia, Columbia, MO. these channels. Although lidocaine is used topically for airway
anesthesia and in a eutectic mixture with prilocaine for skin anesthesia,
INTRODUCTION: This study was conducted to investigate molecular investigators have shown that other local anesthetics, i.e. dyclonine4 and
mechanisms by which local anesthetics produce anesthesia.
Experimentally, local anesthetics inhibit a variety of ion channels tetracaine5 , which belongs to the ester family, provide more intense
including voltage-gated Na channels, voltage-gated Ca channels, and K topical anesthesia. One explanation for this difference may be the
channels. Recently, tetracaine was reported to inhibit cyclic nucleotide- greater inhibition of CNG channels.
REFERENCES:
gated ion (CNG) channels1. These non-selective cation channels located 1. J Gen Physiol. 109:3, 1997.
in plasma membranes are activated by cAMP and cGMP. They are 2. Advances in Second Messenger and Phosphoprotein Research
found in retinal rod cells, olfactory sensory neurons, brain, spinal cord, 33:231, 1999.
heart and other tissues2. In this study we tested the hypothesis that a 3. Pflugers Arch. 391: 85, 1981.
variety of other local anesthetics also inhibit CNG channels. 4. Anesthesiology 94:423, 2001.
METHODS: Experimental procedures were in accordance with the 5. British Journal of Anaesthesia 81:972,1998.
APS/NIH guidelines and were approved by our institutional Animal
Care and Use Committee. Mature Xenopus laevis frogs were
anesthetized, sacrificed, and retinas removed. The excised, inside-out
configuration of the patch clamp technique3 was used to record cGMP
activated currents from individual rod cells, a rich source of CNG
channels. Anesthetics were added to the cytoplasmic side of the
membrane patches.
RESULTS: All twelve local anesthetics inhibited cGMP activated ion
currents as shown in the figure. However, dyclonine (DY), tetracaine
(TE), benoxinate (BX), dibucaine (DI), and pramoxine (PX) were
potent blockers of the CNG channels. In contrast, lidocaine (LI),
etidocaine (ET), mepivacaine (MP), procaine (PC), benzocaine (BZ),
and bupivacaine (BU) were weak blockers. Mexiletine (MX) blocked
with an intermediate potency.
DISCUSSION: All of the local anesthetics that we studied inhibit these
channels; however, local anesthetics commonly used for topical
anesthesia, i.e., dyclonine, tetracaine, benoxinate, dibucaine, and
pramoxine, exhibited significantly greater inhibition of these channels.
Inhibition of the CNG channels did not correlate with local anesthetic
S-253 2003; 96; S-1–S-293
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LOCAL ANESTHETICS INHIBIT THE 5-HT3 RECEPTOR VIA mutant receptors increased 2-3 fold except that of tetracaine in W62Y
DIFFERENT MECHANISMS AND SITES OF ACTION receptor (6-fold).
CONCLUSION AND DISCUSSION: The ester type LAs, procaine
AUTHORS: K. Ueta, T. Suzuki, I. Uchida, T. Mashimo and tetracaine may act at the different site and with different mechanism
AFFILIATION: Osaka Medical School, Suita, Japan. from the amide-type LAs. Procaine inhibits 5-HT3A receptor most
potently by acting the similar point of interaction to 5-HT with the
INTRODUCTION: The 5-HT3 receptors are diffusely distributed in binding domain.
the central and peripheral nervous system and are thought to be
involved in physiological and pathological processes mediating
peripheral and central nociception. To explore other analgesic actions of
local anesthetics (LAs) than their blocking actions for voltage Na+
channel, we investigated mechanisms and sites of action of LAs on
recombinant wild-type and four mutant 5-HT3 receptors.
METHODS: The cRNAs from human wild-type and four mutant 5-
HT3A subunit clones were synthesized in vitro. The homomeric wild-
type and mutant 5-HT3A receptors were expressed in Xenopus oocytes.
Site-directed mutagenesis in N-terminal extracellular region, which
involves the agonist binding domain, was carried out to make four
mutant receptors. Tryptophan (W) at position 62 was replaced to
tyrosine (Y), W at position 155 to Y, and glutamate (E) at position 101
to aspartate (D) or to asparagine (N), respectively. The
electrophysiological recording was made by using the two-electrode
voltage clamp technique and the peak currents induced by 5-HT (EC30)
in these receptors were measured and compared in the presence and
absence of LAs. All data were expressed as mean±s.e..
RESULTS: All LAs inhibited 5-HT-induced currents in dose-
dependent manners in the wild-type receptor. The half maximum
concentrations (IC50s) were 2.71±0.42 M for procaine, 22.6±2.67 M for
tetracaine, 58.5±8.3 M for bupivacaine and 506±35.1 M for lidocaine.
The rank order of potency for inhibitions of s by LAs was different from
that for voltage-dependent Na+ channel. Inhibitions of procaine and
tetracaine were competitive whereas those of bupivacaine and lidocaine
were both non-competitive and competitive. Four mutants (W62Y,
E101D, E101N and W155Y) could all form the functional receptors.
All mutant receptors exhibited drastic increase (> 10 fold) in the IC50s
of procaine. The IC50s of tetracaine, bupivacaine and lidocaine in
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VENTRICULAR FIBRILLATION IS LIKELY TO APPEAR AT constant flow of 40 mL/min-1 with a Krebs-Henseleit buffer.
THE MOMENT ON THE DECLINE OF THE BUPIVACAINE Electrocardiogram was recorded using surface electrodes. After 10 minutes
CONCENTRATION IN RABBITS - COMPARATIVE stabilization period drug infusion was begun by 6-min-step increments, and
PHARMACODYNAMIC STUDY OF THE CARDIOTOXITY after maximum dose by 6-min-step decrements. Each group (n=5 each)
received lidocaine (from 37 µmol/l to 123 µmol/l), bupivaicaine (from 3
BETWEEN THE RACEMIC AND LEVO BUPIVACAINES µmol/l to 100 µmol/l) and levo-bupivacaine (from 62 µmol/l to 500 µmol/
AUTHORS: N. Kariya1, S. Nishi2, A. Asada1, J. Mazoit3 l). QRS and RR intervals were measured for each concentration at the end
AFFILIATION: 1Department of Anesthesiology and Intensive Care of a 6 min-step. Results are fitted to Emax model with computer software
(SAAM II®) as follows. The change of EC50 between increment and
Medicine, Osaka City University Medical School, Osaka, Japan, 2Division decrement of the dose was evaluated with repeated-measures analysis of
of Intensive Care, Osaka City University Medical School, Osaka, Japan, variance with the aid of the Scheffe post hoc method.
3
Laboratoire d'Anesthésie UPRES EA 392, Université Paris-Sud, Faculté RESULTS: With bupivacaine, ventricular fibrillation (Vf) (n=4, 80%) was
de Médecine du Kremlin-Bicêtre, Kremlin-Bicêtre, France. observed in the decrement slope. All the value of EC50 for QRS interval of
decrement slope is significantly smaller than increment slope (Table 1) (*;p
We studied the pharmacodynamics on the prolongation of QRS or RR < 0.05, **;p < 0.01). EC50 for RR of decrement slope is significantly
intervals by bupivacaine in vivo model and isolated perfused rabbit heart to smaller than that of increment slope with lidocaine and levo-bupivacaine.
elucidate the phase of fatal cardiac arrhythmia. In vivo study; Eight male However, EC50 for RR of decrement slope is significant larger than that of
New-Zealand rabbits were anesthetized with pentobarbital and increment slope with bupivacaine (Table 2, Fig 2).
mechanically ventilated. Bupivacaine (1mg/kg/min, totally 7mg/kg) were DISCUSSION: Bupivacaine in the decrement course was thought to
infused. Electrocardiogram was recorded. Serum bupivacaine minimize the differences between RR and QRS intervals and then is likely
concentration of the samples (0, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 30 and 40 to cause fatal cardiac arrhythmia like as ventricular fibrillation. Compared
minutes) was measured with HPLC. Result: The prolongation of QRS is with levo-bupivacaine and lidocaine, bupivacaine is more likely to lead to
delayed from RR. The frequency of ventricular tachycardia after the peak fatal arrhythmia with clinical possible dose in the concentration decrement
concentration was 100% and that before the peak concentration was 37.5%. slope. In conclusion, these results would make it possible to suppose the
(Fig 1) concentration of serum bupivacaine when the fatal arrhythmia occurs. Not
only prolongation of QT interval but cardiac excitability may be concerned
with the fatal arrhythmia by bupivacaine.
Table 1
QRS Bupivacaine Levo-Bupi Lidocaine
Increment 25.4 ± 18.7 410 ± 298 232 ± 112
Decrement 12.2 ± 7.70** 174 ± 64.2* 121 ± 90.7**
Table 2
Langendorff preparation; Fifteen male New-Zealand rabbits, were allocated
randomly into three groups. The rabbits were anesthetized with RR Bupivacaine Levo-Bupi Lidocaine
pentobarbital. The animals were mechanically ventilated and after iv Increment 52.0 ± 26.8 420 ± 236 241 ± 123
heparin injection, the heart was removed and was retrogradely perfused at a Decrement 66.4 ± 17.1* 189 ± 86.1* 134 ± 90.7**
2003; 96; S-1–S-293
S-254
MECHANISMS AND SITE OF ACTION FOR TIME- GDP-GTP exchange and not dependent on increased GTPase activity,
DEPENDENT INHIBITION BY LOCAL ANESTHETICS phosphatases or proteinkinases. Thus, clinically relevant effects, based
on GPCR signaling, might be attenuated more potent by continuous
AUTHORS: M. W. Hollmann application of LA.
AFFILIATION: University of Heidelberg, Heidelberg, Germany. REFERENCES:
[1] Hollmann MW et al. Anesthesiology 2000; 93:858-875,
INTRODUCTION: Several beneficial effects of local anesthetics (LA) [2] Hollmann MW et al. Mol Pharmacol 2001; 59:294-301.
were shown to be due to inhibition of G protein-coupled receptor
(GPCRs) signaling. Differences in exposure time might explain at least Supported in part by the 2002 Ben Covino Research Award, sponsored
in part the discrepancies in concentrations of LA required to achieve by AstraZeneca, Sweden and by the Departments of Anesthesiology
these protective effects in vivo and in vitro (approximately 100 fold University Hospitals Maastricht (The Netherlands) and Heidelberg
higher) [1]. We therefore studied time-dependent effects of LA on (Germany).
GPCR-signaling and characterized possible mechanisms and sites of
action, employing Xenopus oocytes and human neutrophils (hPMNs).
METHODS: To assess LA effects on GPCR-signaling in oocytes and
primed and and activated hPMNs, agonist-induced Ca2+-activated Cl--
currents (ICl(Ca)) were measured at different time points (10min - 48h),
using 2-electrode-voltage-clamp-technique, and superoxide anion
production was determined by cytochrome c-reduction assay,
respectively. Antisense knock down of Gq protein [2] and inhibition of
various proteins within the signaling pathway served for defining
mechanisms and sites of action more specific. Data are shown as
mean±sd. Statistics: one-way ANOVA (Dunnett correction); p<0.05
was considered statistically significant.
RESULTS: LA attenuated GPCR-signaling in both models in a time-
dependent and reversible manner (lidocaine reduced LPA-signaling to
19±3% after 48h of control response in oocytes and 25±2 % after 6h in
hPMNs, respectively). Intracellularly injected QX 314, a lidocaine-
analog, exerted similar time-dependent effects, whereas QX 314
applied extracellularly or injected intracellularly in Gq-depleted oocytes
as well as inhibition of phosphatases or proteinkinases and agonist-
independent G-protein stimulation, using guanosine-5’-O-3-
thiotriphosphate (GTPS) or aluminumflouride (AlF) did not affect time-
dependent inhibition by LA at all.
DISCUSSION: In summary our study could show that inhibition of
GPCR-signaling by LA is time-dependent and reversible. Critically
requiring Gq protein-function, this effect is located downstream of
Pharmacology -
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Clinical
PHARMACOLOGY -
CLINICAL
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CHARACTERIZATION AND MANAGEMENT DEXMEDETOMIDINE- DEX loading dosing (total dose or rate of infusion) may be advisable to
RELATED HYPOTENSION FOLLOWING CABG reduce the risk of hypotension.
AUTHORS: V. Jorden1, D. L. Herr2
AFFILIATION: 1Abbott Laboratories, Abbott Park, IL, 2Washington
Hospital Center, Washington, DC.
INTRODUCTION: Dexmedetomidine (DEX), a new alpha-2 agonist
sedative, may reduce blood pressure through centrally-mediated
sympatholysis. This analysis, part of a large, prospective study of post-
CABG sedation, was undertaken to quantify the nature of DEX-induced
hypotension when compared to propofol (PROP).
METHODS: Following IRB approval at each center and informed
consent, subjects were prospectively randomized to either DEX or
PROP sedation post-CABG. Investigators determined whether a given
blood pressure represented hypotension for each subject, after which
any combination of the following were available for therapy: fluid
bolus, patient repositioning, reduction of sedative infusion, reduction of
concurrent vasodilator infusion, and initiation of vasopressors.
RESULTS: 308 subjects (DEX 153, PROP 155) were enrolled at 25
sites. Hypotensive events were more common in the DEX group (DEX
43 events in 36 subjects vs. PROP 28 events in 28 subjects); 26% of all
events in the DEX group occurred within one hour of the 1 mcg/kg
loading dose. A similar percentage of events in either group was
successfully treated with a combination of fluids and repositioning: Dex
27% (11/43) vs. PROP 29% (8/28). Reduction of sedative and/or
vasodilator infusions were successful in an additional 22% (10/43)of
the Dex group vs. 15% (4/28) of the PROP group. Vasopressors alone or
combined with other therapies were necessary for 51% (22/43) of the
DEX group vs. 57% (16/28) of the PROP group. One subject in either
group required cardioversion or pacing to restore normotension.
CONCLUSIONS: While hypotensive events occurred more frequently
in the DEX group than in the PROP group, the PROP group had a
slightly higher need for pressors. These findings suggest that the risk of
refractory hypotension requiring pressors is similar among patients
receiving DEX or PROP following CABG, and that modifications in the
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INTRAOPERATIVE DEXMEDETOMIDINE INDUCED transmitted light through the fingertip decreased significantly (p<0.05).
VASOCONSTRICTION Systolic blood pressure remained unchanged.
DISCUSSION: In surgical patients under general anesthesia 1g/kg
AUTHORS: C. K. Stapelfeldt, R. Brown, E. Lobo, P. Talke dexmedetomidine caused peripheral vasoconstriction (as measured by
AFFILIATION: University of California San Francisco, San transmitted light through the finger) and a decrease in heart rate
Francisco, CA. throughout the15 minute infusion. However, the increase in blood
pressure was limited in duration. Intraoperatively, under general
INTRODUCTION: Alpha-2 adrenoceptor agonists have both centrally anesthesia we were able to observe vasoconstriction induced by
mediated sympatholytic and peripherally mediated vasoconstrictive dexmedetomidine with minimal interference from the sympatholytic
effects. Dexmedetomidine, an alpha-2 agonist, causes peripheral effects on the drug.
vasoconstriction in young healthy volunteers during general anesthesia.
The aim of this study was to determine the vasomotor effects of an
intraoperative dexmedetomidine loading dose infusion during general
anesthesia.
METHODS: After Human Research Committee approval and written
informed consent 24 patients scheduled for elective surgery were
studied in an open label design. Direct arterial blood pressure, heart rate
and infrared light (nA) transmitted through the fingertip were monitored
continuously, and recorded electronically every 10 seconds. An increase
in transmitted light indicates a decrease in finger blood volume (i.e.
vasoconstriction). A 1g/kg dexmedetomidine zero order infusion was
administered over 15 minutes intraoperatively during general
anesthesia. Maximum hemodynamic changes during infusion and
values at the end of infusion were compared to pre-dexmedetomidine
values by repeated measures ANOVA followed by Dunnett’s post hoc
test. We also compared values at the end of infusion to values 5 minutes
after infusion using paired t-test.
RESULTS: Intraoperative dexmedetomidine infusion increased
transmitted light through the fingertip (p<0.001) and systolic blood
pressure (p=0.004), and decreased heart rate (p<0.001). Maximum
increase in transmitted light through the fingertip was 29 ± 25 %. The
increase was 29 ± 24 % at the end of infusion. Dexmedetomidine
increased systolic blood pressure from 109 ± 16 mmHg to a maximum
of 126 ± 18 mmHg. At the end of infusion systolic blood pressure was
115 ± 25 mmHg (p=NS). Dexmedetomidine decreased heart rate from
68 ± 14 bpm to a minimum of 62 ± 10 bpm at the end of infusion. In the
first 5 minutes after the dexmedetomidine infusion, only heart rate and
2003; 96; S-1–S-293 S-258
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THE EFFECT OF LISTENING TO HEMISPHERIC undergoing lumbar procedures were given similar amounts of fentanyl
SYNCHRONIZATION ON THE AMOUNT OF regardless of whether they listened to Hemi-Sync or a blank tape
INTRAOPERATIVE ANALGESIA REQUIRED (0.0147 ug/kg/min (0.00909) vs. 0.0124 ug/kg/min (0.0116)).
Regression analysis showed no statistically significant correlation
AUTHORS: A. Lewis, I. Osborn, R. Roth between age or sex and fentanyl requirement for either procedure.
AFFILIATION: Mount Sinai School of Medicine, New York, NY. DISCUSSION: Interestingly, there was a dichotomy in the results.
Listening to Hemi-Sync intraoperatively decreased the amount of
INTRODUCTION: Innovative types of music are prevalent for analgesia administered for bariatric surgery. In contrast, the amount of
relaxation and hypnosis. Surgical patients are able to process auditory analgesia administered for lumbar procedures was not correlated with
input while under general anesthesia. (1,2) Hemispheric exposure to Hemi-Sync. The difference in analgesic requirement among
synchronization music (Hemi-Sync) is a stereophonic vibrato of two the lumbar cases may not have been apparent because of an induction
sounds, producing a binaural beat stimulating the thalamus and cortex, dose of 100 ug fentanyl which could have been excessive considering
affecting awareness. (3) A previous study established that Hemi-Sync the low degree of surgical stimulation. Hemi-Sync was proven to
can successfully be used as an adjuvant to general anesthesia, but complement analgesia in laparoscopic bariatric surgery and certainly
patients underwent a variety of procedures and requirement of analgesia deserves further evaluation.
was evaluated based on hemodynamics alone. (4) The current double- REFERENCES:
blind randomized study of 60 patients undergoing general anesthesia for (1) Anesthesia and Analgesia 1998; 86: 1084-9.
either laparoscopic bariatric or lumbar surgery employed bispectral (2) British Journal of Anaesthesia 1998; 80: 133-139.
index monitoring (BIS) to ensure equivalent depth of hypnosis in (3) Journal of Scientific Exploration 1997; 11 (3): 263-74.
addition to using hemodynamics as a determinant of analgesia (4) Anaesthesia 1999; 54: 769-73.
requirement.
METHODS: Consented patients were randomized to hear either a
blank tape or Hemi-Sync. The same physician anesthetized all patients
undergoing a particular procedure. Following endotracheal intubation,
headphones were applied. The patient was not disturbed for the first ten
minutes of tape play to determine baseline heart rate and blood
pressure. The concentration of inhalational agent was adjusted by
increments of 0.3% every five minutes as needed to maintain BIS at a
depth of 50 ± 10. Fentanyl was administered in boluses of 25 ug every
five minutes if heart rate and/or systolic blood pressure were above
baseline values by 15% and 20%, respectively. The headphones were
removed at the time of instrument removal and the initiation of skin
closure. Amount of fentanyl administered per kilogram, per minute,
during the trial period was compared using a student's t-test.
RESULTS: Bariatric patients who listened to Hemi-Sync were given
one-third less fentanyl than those listening to a blank tape (0.0152 ug/
kg/min (0.00884) vs. 0.0242 ug/kg/min (0.00865)) (p<0.01). Patients
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A NOVEL MIXTURE OF PROPOFOL, ALFENTANIL AND rate change, need for airway support, or recall between the 2 groups. No
LIDOCAINE IN OBESE VS. NORMAL WEIGHT PATIENTS N&V or pain to mixture infusion in both groups. Systolic BP(SBP) was
FOR SEDATION IN OPHTHALMIC PROCEDURES significantly increased from baseline with 17.04 + 21.78 mmHg
(P<0.0000) for non obese and 9.6 + 23.98 mmHg(P=0.016) for obese
AUTHORS: Z. Fang, M. A. Keyes, F. Sabzevar patients prior to IV sedation. After sedation and block, SBP was
AFFILIATION: David Geffen School of Medicine at UCLA, Los decreased comparing to the baseline, with –3.22 + 20.73 mmHg
Angeles, CA. (P=0.28) for non obese and –13.70 + 22.37 mmHg (P <0.001, but <
10% from the baseline) for obese groups. See table for further results.
INTRODUCTION: IV sedation in obese patients presents clinical
challenge because of difficulty in appropriate dose determination which Apnea with
Patient &
can lead to over or under sedation. We studied a mixture of 6ml Group # pt BMI
Had Sec/ No hm/ ebm
airway
Brief O2 surgeon
propofol (10mg/kg), 2ml alfentanil (500g/ml) and 2ml 2% lidocaine ss/drr ebm/cop only
support
desaturation satisfactory
(A6-2-2) for IV sedation during regional block for ophthalmic surgery. score
With IRB approval, this retrospective review compared the effects of 9.81+0.53
Obese 40 30.93+3.58 31(78%) 31(78%) 3(8%) 1 3
A6-2-2 mixture in obese patients vs those of normal weight. 9.64+0.7
METHODS: Obesity was defined as body mass index (BMI) >26. If Non 23.16+1.87 40(82%) 38(78%) 8(16%) 9.73+0.64
patient was obese, weight for dosing was calculated as ideal body obese
49
(P<0.0001) (P=0.79) (P=0.99) (P=0.33)
1 2
9.57+0.84
weight (IBW) plus 30% of (patient‘s weight- IBW). Bolus of A6-2-2
mixture was delivered by infusion pump based on alfentanil dose CONCLUSION: The effect of novel mixture of propofol, alfentanil
according to age. Age >74, 5g/kg; 65-74, 6g; 55-64, 7g; 45-54, 8g; and and lidocaine (A6-2-2 mixture) in obese patients was comparable to non
<45, 9g/kg. Following bolus, mixture was infused at 0.75 g/kg/min obese patients when dosage adjusted as described. This simple mixture
alfentanil until block completion. Block performed at 1 minute after provided excellent(no hm, ebm or cop) or good (ebm only) sedation/
bolus finished. All patients received O2. They were monitored for vital analgesia for majority patients in both groups. The mixture also
signs, 3 signs of sedation including spontaneous eye closure(sec), provided hemodynamic stability with similar low incidence of airway
sluggish speech(ss), and decrease in respiratory rate(drr), 3 responses to complication and no N&V or pain due to infusion.
regional block including head movement(hm), eyebrow
movement(ebm) and complaint of pain(cop), airway complication, N &
V, pain to mixture infusion and recall. Patient and surgeon satisfaction
(1-10) scored based on standardized questioning. Exact chi-square and
T test or corresponding Wilcoxon rank sum test were used for statistic
analysis. P<0.05 was considered significant.
RESULTS: 89 charts were reviewed. 40 of 89 patients were obese.
There was no significant difference in age or gender between groups.
The difference in BMI was significant (P<0.0001). No significant
difference in % of patients presenting all 3 signs of adequate sedation
and analgesia without 3 responses to block in both groups. No
significant difference in incidence of apnea, oxygen desaturation, heart
S-260 2003; 96; S-1–S-293
S-259
SEDATION WITH SEVOFLURANE OR PROPOFOL IN CONCLUSIONS: Sevoflurane for sedation produces similar recovery
PATIENTS UNDERGOING REGIONAL ANESTHESIA FOR of cognitive function as measured by DSST and memory scores
ORTHOPEDIC SURGERY compared with propofol. Both agents can be recommended for sedation
during regional anesthesia.
AUTHORS: M. Taboada, L. Helgeson, A. Bustos, R. Aouad, P. G.
Atanassoff
AFFILIATION: Yale University, New Haven, CT.
INTRODUCTION: Sedation for surgical procedures performed under
regional anesthesia has usually been accomplished with intravenous
agents such as midazolam or propofol, whereas volatile anesthetics are
rarely used for this purpose. Sevoflurane for sedation and induction of
general anesthesia has been suggested because of its characteristics of
non-pungency, rapid induction, and quick elimination. The purpose of
this investigation was to compare the quality of sedation and recovery
following use of either sevoflurane or propofol sedation during regional
anesthesia.
METHODS: Thirty-seven patients undergoing orthopedic surgery with
regional anesthesia were enrolled in a randomized investigation
comparing sedation with sevoflurane (n=17) and propofol (n=20).
Level of sedation was targeted to an Observer's Assessment of
Alertness--Sedation score of 3 (OAAS=3, responds slowly to voice).
Recovery from sedation was assessed objectively by Observer's
Assessment of Alertness--Sedation, Digit Symbol Substitution Test
(DSST) and memory scores.
RESULTS: All patients were assessable for efficacy and recovery data.
Sevoflurane and propofol produced dose-related sedation. Recovery
from sedation to OAAS 5 (fully awake) after surgery was similar
between groups, 7±3 min and 8±3 min for sevoflurane and propofol,
respectively (p=ns). Seventy-one percent (sevoflurane) of the patients
compared with 60% (propofol) returned to baseline DSST at 30 min
postoperatively (p=ns). Short and long term memory tests yielded
similar results between the two groups (p=ns). Excitation was seen in
seven of 17 patients receiving sevoflurane and three in those sedated
with propofol. Discharge eligibility was deemed earlier with
sevoflurane (48±7 min) than with propofol (55±9 min, p<0.05).
S-260
ROUTINE USE OF PREOPERATIVE BETA-BLOCKERS DOES baseline PAT HR (p 70bpm nearly doubled (25.9% to 48.1%), while
NOT BLUNT STRESS (HEART RATE) RESPONSE TO patients with HR rate <60bpm nearly halved (table). The difference in
IMPENDING SURGERY systolic and diastolic BP was not significantly different between BB-
patients and noBB-patients.
AUTHORS: S. Akhtar1, M. Amin2, J. Whipple2, H. Tantawy2, P. G. CONCLUSION: Our study suggests despite routine preoperative beta-
Barash2, D. G. Silverman2 blocker use and reasonable preoperative heart rate, stress response to
AFFILIATION: 1VA Connecticut Healthcare System, West Haven, CT, impending surgery is not effectively blunted. Prophylactic supplemental
2
Department of Anesthesiology, Yale University School of Medicine, doses of BB may be required perioperatively even in patients who are
on routine BB to blunt the HR response effectively in significant
New Haven, CT. number of patients.
INTRODUCTION: b-blockers (BB) decrease post-operative cardiac
morbidity and mortality1. Of the proposed mechanisms associated with Age (mean) Patients with HR Patients with HR >60 Patients with HR
Patients
their beneficial effects, a decrease in oxygen demand secondary to (SD) <=6 And <=70 >=71
decreased chronotropy is hypothesized to play a major role. Recent BB Patient
ACC/AHA Guidelines recommend titrating preoperative BB to Pre-Op HR 75/197(38.05%) 71/197(36.04% 51/197(25.88%)
maintain resting heart rate (HR) between 50-60 bpm2. We recently 67.09
showed that, despite beta-blocker use, only 38% of patients receiving Initial HR 39/210(18.57%)* 70/210(33.33%)* 101/210(48.09%)
(7.07)
routine BB had HR =60 bpm and 26% still had HR =70 bpm. This study Non-BB Patients
was conducted to determine if routine use of BB blunts the stress
response (HR) to impending surgery, as a measure of effective Pre-Op HR 16/129(12.04%) 43/129(33.33%) 70/129(54.26%)
blockade. Initial HR
69.12
18/138(13.04%) 29/138(21.01%)* 91/138(65.94%)*
METHODS: A retrospective review of the pre-anesthetic assessment (28.28)
record was conducted on 326 consecutive patients who were scheduled
to undergo major vascular surgery (CEA, supra and infrainguinal REFERENCES:
bypass, thoracic and aortic abdominal aneurysm) and CABG between 1. NEJM 341(24);1789, 1999
Jan 2001 to March 2002 at Yale-New Haven Hospital. Demographic 2. JACC 39(3), 2002
data, medications, pertinent review of systems and resting HR and BP,
while in the Pre-Admission Center, were obtained from the electronic
records. Initial intraoperative HR and BP were obtained from chart
review. Patients were grouped as: i) patients on BB (BB-patients), ii)
patients not on BB (noBB-patients). Data are presented as mean ±SD
and analyzed by unpaired t-test with Welch correction. P < 0.05
considered significant.
RESULTS: 60.43% (197/326) of patients scheduled surgery were on
BB (mean PAT HR 65bpm ±14.85). 39.57% (129/326) were not on
routine BB (HR 74.5bpm±0.71). Initial intraoperative HR in BB-
Patients was 70.83bpm±2.83 and was significantly different from
2003; 96; S-1–S-293 S-262
S-261
CHRONIC BETA-ADRENOCEPTOR BLOCKADE DOES NOT adrenoceptor blockade; or are there fundamental differences in the
MINICK ACUTE MEDICATION IN ITS EFFECTS ON patient populations between the acute and chronic studies? Furthermore
CARDIAC OUTCOME are there biochemical or pharmacological differences in the stress
responses to anesthesia and surgery in patients receiving acute -
AUTHORS: J. W. Sear, J. Giles adrenergic blockade compared with chronic medication?
AFFILIATION: University of Oxford, Oxford, United Kingdom. REFERENCES:
1. Anesthesiology 1988; 68: 495-500.
INTRODUCTION: A number of studies and RCT's have 2. N Engl J Med 1996; 335: 1713-1720.
demonstrated an effect of acute -adrenoceptor blockade on 3. Anesthesiology 1998; 88: 7-17.
perioperative cardiac outcomes in both high risk and other populations 4. Anesth Analg 2000; 90: 1257-1261.
undergoing non-cardiac surgery (1-6). However there are fewer data on 5. Anesth Analg 1998; 88: 477-482.
the efficacy of intercurrent chronic -adrenoceptor blockade (whether 6. N Engl J Med 1999; 341: 1789-1794.
given for the treatment of ischemic heart disease or hypertension) with 7. JAMA 1992; 268: 205-209.
regard to cardiac morbidity and mortality in comparable patient groups. 8. Br J Anaesth 2000; 84: 311-315.
METHODS: We conducted a MEDLINE search for papers evaluating 9. JAMA 1992; 268: 228-232.
the effects of chronic medication on cardiovascular outcomes. The 10. Anesthesiology 1998; 88: 572-578.
terms used were 'perioperative care; postoperative complications; 11. Circulation 1999; 100: 1043-1049.
adrenergic antagonists; adrenergic beta-antagonists; myocardial 12. JAMA 2001; 285: 1865-1873.
ischemia; myocardial infarction; mortality and heart disease mortality', 13. Br J Anaesth 2001; 86: 506-512.
followed by hand searching of reference lists from the identified papers. 14. Br J Anaesth 2003 - in press
We identified 8 studies (7 observational; 1 case-control [CC] linkage
study with matched non -blocked controls). Various endpoints SMI postop n odds ratio
measured within 30 days of surgery were examined in the different
studies - cardiac death plus/ minus major cardiac complications [n=4]; Hollenberg (7) 407 1.58 (0.78-3.14)
major complications alone [1]; postoperative myocardial infarction [1] Sear (8) 453 0.67 (0.37-1.21)*
and postoperative silent myocardial ischemia (SMI) [2]. Major cardiac complications and death
RESULTS: Overall the studies encompass 6343 patients (1290
receiving chronic -adrenergic blockade; 20.3%). Individual odds ratios Browner (9) 474 2.4 (1.0-5.5)
(and 95% CI) for the endpoints are shown in the table: Badner (10) 323 1.48 (0.56-3.97)
[Univariate odds ratios except * where adjustment made for possible Lee (11) 2893 1.34 (0.71-2.51)
confounders].
DISCUSSION: With the exception of Browner (13) (which examined Boersma (12) 1351 0.59 (0.25-1.25)
in-hospital mortality), there were no significant differences from unity. Sear [CC] (13) 230 1.00 (0.41-2.44)*
This is in contrast to acute studies where most show significant Sear (14) 212 1.61 (0.65-3.76)
reductions in morbidity and mortality with acute -adrenoceptor
blockade (1-6). This leads to two important questions - what should be
done for 'at-risk' patients presenting for surgery and already on -
S-262
THE EFFECTS OF ACETAMINOPHEN ON THE (p<0.45) for control and the acetaminophen group, respectively. The
PHARMACOKINETICS OFORAL MIDAZOLAM. AUC‘s calculated for the control and acetaminophen group were 93 ±
99 and 85 ± 64 ug-min/ml (p<0.24), respectively.
AUTHORS: D. E. Feierman, L. A. Coore, J. Silverstein DISCUSSION: Since acetaminophen and midazolam are metabolized
AFFILIATION: The Mount Sinai School of Medicine, New York, NY. by the CYP3A4 in humans, it was hypothesized that acetaminophen
might affect the pharmacokinetics of midazolam. The results show that
INTRODUCTION: The goal of this study was to characterize the acetaminophen had little effect on Cmax and AUC of midazolam.
interactions of acetaminophen with midazolam in humans. Although they are metabolized by the same P450, it has been previously
Acetaminophen and midazolam are metabolized by cytochrome P450 shown that acetaminophen has a high Ki (3mM) for the inhibition of
(CYP) 3A. Oral administration of midazolam results in significant fentanyl metabolism (3). It appears that at the dose tested,
CYP3A mediated-first pass metabolism (1). Since acetaminophen and acetaminophen has little effect of the disposition of midazolam.
midazolam will compete for CYP3A4, and this P450 plays a major role REFERENCES:
in the first-pass-metabolism; we have designed a study to ascertain the 1) Gorski, J.C., et al., Clin Pharmacol Ther, 1998. 64(2): p. 133-43.
effects of acetaminophen on the pharmacokinetics of midazolam. The 2) Thummel, K.E., et al., J Pharmacol Exp Ther, 1994. 271(1): p. 549-
working hypothesis was that CYP3A4 mediated metabolism would be 56.
inhibited by acetaminophen and thereby increase Cmax and AUC of 3) Feierman, D.E., Acta Anaesthesiol Scand, 2000. 44(5): p. 560-3.
orally administrated midazolam.
METHODS: The protocol was conducted in the General Clinical
Research Center of the Mount Sinai School of Medicine after
Institutional Research Board approval was obtained. A double-blind
randomized study of 16 human volunteers was performed to determine
the pharmacokinetics, specifically Cmax and AUC, of oral midazolam
in the presence of tacetaminophen or a placebo. Each volunteer
underwent two testing periods, each at least 2 weeks apart. In a random
sequence, each patient received one of the following combinations: I-
Placebo (cherry syrup)* + Midazolam (0.3 mg/kg) or II-Dose 2 of
acetaminophen syrup(15 mg/kg)* + Midazolam (0.3 mg/kg). Blood
samples were acquired at 0, 15, 30, 45, 60, 90, 120, 180, 240 and 480
minutes. The blood was centrifuged and the plasma stored at –40oC
until analyzed. Blood samples were analyzed for midazolam by the
method of Thummel et al. (2) using a Hewlett-Packard Model 5972
mass-selective detector (MSD). Results are expressed as the mean ± SD
and were analyzed with a Student paired t-test (one tailed).
RESULTS: Cmax and AUC were estimated using PK Solutions 2.0
pharmacokinetics program (Summit Research Services, Ashland, OH).
The co-administration of acetaminophen and midazolam had no effect
on Cmax or AUC. Cmax‘s were 247 ± 258 and 242 ± 126 ng/ml
S-264 2003; 96; S-1–S-293
S-263
APPREARANCE OF ROFECOXIB, A SELECTIVE the rofecoxib administration, including the delay to reach CSF levels,
CYCLOOXYGENASE-2 (COX-2) INHIBITOR, IN may be one factor determining efficacy for this and other COX-2
CEREBROSPINAL FLUID FOLLOWING ORAL inhibitors.
ADMINISTRATION IN PATIENTS REFERENCES:
(1) Regional Anesth Pain Med 2002;27(in press).
AUTHORS: A. Buvanendran1, J. S. Kroin1, P. Luk2, I. W. Rodger2, K. (2) Nature 2001;410:471.
J. Tuman1 (3) J Neurosci 2001:21:5847.
AFFILIATION: 1Dept. of Anesthesiology, Rush Medical College, (4) Nature 2001;410:425.
(5) Anesthesiology 2001;95:A868.
Chicago, IL, 2Merck Frosst Canada, Kirkland, PQ, Canada. (6) Anesth Analg 2000;91:1221.
INTRODUCTION: We have recently demonstrated in an animal
model of post-operative pain that intrathecal COX-2 inhibitors can
modulate hypersensitivity (1). Intrathecal COX-2 inhibitors can also
reduce hypersensitivity in inflammatory animal pain models (2,3).
Therefore, blood-brain-barrier penetration may be an important factor
in the analgesic effectiveness of oral COX-2 inhibitors (4). Following
oral administration of rofecoxib in rats, the compound appears in the
cerebrospinal fluid (CSF) at a concentration 19-35% of the plasma level
(5). The purpose of this study is to investigate the time course of
rofecoxib in CSF when administered orally to patients undergoing total
knee arthroplasty (TKA).
METHODS: Following IRB approval and informed consent, 11
patients scheduled for TKA received a dose of rofecoxib 50 mg both 24
h and just before surgery, as part of a analgesic regimen. All patients
had combined spinal-epidural (CSE) anesthesia for the surgery, and
CSF (100 L) samples were obtained prior to intrathecal administration
of local anesthetic as part of the CSE technique. The range of time delay
between the last oral administration and the CSF sampling ranged
between 17-85 min. Rofecoxib concentration was assayed by HPLC.
RESULTS: For patients receiving oral rofecoxib, the CSF
concentration was below 0.06 g/mL for the first 60 min after the post-
surgery oral dose (Fig.). After 60 min, the CSF level was above 0.06 g/
mL (p<0.005, Fisher’s exact test).
DISCUSSION: Following oral administration, there is a 60 min delay
before CSF rofecoxib levels increase. Oral rofecoxib (50 mg) has been
shown to reduce post-operative opioid use following spinal fusion when
given 60 min before anesthetic induction (6). Therefore, the timing of
S-264
THE EFFECT OF FENTANYL ON RENAL TUBULAR
FUNCTION AND NDOCRINE RESPONSE DURING
THORACOTOMY
AUTHORS: S. Sonoda
AFFILIATION: Juntendo University School of Medicine, Bunkyo-
ku,Tokyo, Japan.
BACKGROUND: Surgical stress produces various endocrine response
including sympathetic hyperactivity and cytocaine release. Those are
reported to associate with renal tubular damage during thoracotomy
previously. Epidural analgesia with local anesthetics only couldn't
prevent renal tubular damage and cortisol release. This study is assigned
to evaluate the effect of fentanyl on those reaction.
METHODS: Thirty patients undergoing elective thoracotomy were
divided into three groups at random. Control group was maintained
under general anesthesia (GA). GA combined with epidural analgesia
with 1% mepivacaine was used on epidural group. Fentanyl was
administered by intravenous and epidural injection addictively on
fentanyl group. Urinary output of N-acetyl-É¿-D-glucosaminidase
(NAG) was measured as an indicator of renal tubular cell damage
before and during the operation. Plasma cortisol and aldosterone were
determined as indicator of the response to surgical injury.
RESULTS: NAG and cortisol increased significantly during
thoracotomy from on control and epidural (p<0.05) but not fentanyl
group. Aldosterone increased significantly by about three times on
control and epidural group (p<0.01), less than twice on fentanyl group
(p<0.05).
CONCLUSIONS: It was demonstrated that the administration of
fentanyl suppress increase of NAG and cortisol completely and
attenuate aldosterone release during thoracotomy. Those results suggest
that fentanyl attenuate endocrine response and prevent renal tubular
damage during thoracotomy.
2003; 96; S-1–S-293 S-266
S-265
IS THERE AN IDEAL APPROACH FOR RAPID SEQUENCE RESULTS: Demographic data and type of medication for anti-
INDUCTION IN HYPERTENSIVE PATIENTS? hypertensive treatment were similar in all groups. Systolic and mean
arterial blood pressure (MAP) at intubation, 1 and 3 min after intubation
AUTHORS: Z. Alanoglu, Y. Ates, A. A. Yilmaz, F. Tuzuner; were higher in group LS compared to groups RS and RR (p<0,01).
AFFILIATION:Ankara University Medical Faculty, Ankara, Turkey. MAP increased at intubation and 1 min after intubation compared to
baseline in groups LS and LR (p<0.01). MAP was similar at all
INTRODUCTION: Hypertensive patients are more prone to exhibit an measurement intervals in group RS. Paramedian position of the vocal
exaggerated hemodynamic response to laryngoscopy and tracheal cords at intubation was higher in group LS(n=7) compared to other
intubation1. So far, the hemodynamic alterations associated with rapid- groups(n=1 for each group) (p<0.05).
sequence induction of anesthesia in hypertensive patients has been DISCUSSION: Rapid sequence induction is generally used under
under evaluated. This randomized, prospective trial was designed to emergent conditions. In this study an ideal approach to maintain
examine the hemodynamic effects of four different rapid sequence cardiovascular stability during rapid sequence induction was searched
induction protocols in hypertensive patients in order to determine the for hypertensive patients. Remifentanil succinylcholine combination
optimal approach for a smooth laryngoscopy and intubation. appears to be more beneficial in terms of hemodynamic stability.
METHODS: After IRB approval and patient consent was obtained; Remifentanil was found superior to lidocaine in attenuation of the
120 hypertensive ASA II-III adult patients undergoing elective surgery response to laryngoscopy and intubation.
were allocated to four groups at random by sealed envelope technique. REFERENCES:
Anticipated difficult airway, ECG evidence of heart block or congestive 1.BJA 2001; 86: 90-3,
cardiac failure were the exclusion criteria. Patient’s lungs were 2.Anesth Analg 1989; 69: 93-99
preoxygenated for 3 minutes, induction and tracheal intubation was
performed in a 30° head-up position. At induction of anesthesia, group
LS(n=30) received a bolus of lidocaine 1,5mg kg-1 over 30 s followed
by thiopental 5-7 mgkg-1 and a bolus of succinylcholine 1 mgkg-1.
Group LR (n=30) received the same induction agents as group LS with
rocuronium 1mgkg-1 for muscle relaxation. Group RS(n=30) received a
bolus of remifentanil 1 mcgkg-1 over 30 s followed by thiopental 5-7
mgkg-1 and a bolus of succinylcholine 1 mgkg-1. Group RR (n=30)
received the same induction agents as group RS with rocuronium 1mg
kg-1 for muscle relaxation. Hemodynamic data (heart rate, non-invasive
blood pressure and peripheral oxygen saturation) were noted before
induction (baseline), after induction, at intubation and at 1, 3, 5, 10, 20
minutes following intubation. 60 s after administration of muscle
relaxant, endotracheal intubation was performed and intubation
conditions were scored2. Anesthesia was maintained with isoflurane
1,5% and N2O 50% in oxygen. ANOVA and chi square tests were used
for statistical analysis. P value <0,05 was considered significant.
S-266
LARINGEAL MASK AIRWAY INSERTION WITH (p<0.05). One hundred percent of patients were assessed as grade 1 in
REMIFENTANIL R2 group while 64.3% in R1 and 27.3% in P groups. No difference in
airway quality was observed between the groups. More patients in P
AUTHORS: H. Yazicioglu, S. Yildiz-Muslu, B. Yamak, O. Erdemli group required additional propofol compared to R2 group (p<0.05).
AFFILIATION: Turkey Yuksek Ihtisas Hospital, Ankara, Turkey. Undesirable responses following LMA insertion; like limb, head
movement or hiccup was observed in 54% of patients in P group.
INTRODUCTION: Propofol is the commonly used anesthetic for the DISCUSSION: Propofol given 2.5mg/kg alone is not a good agent for
induction of anesthesia for insertion of laryngeal mask airway (LMA). LMA insertion. Remifentanil used in both doses combined with
When used alone, propofol may be inadequate to blunt undesirable propofol provides excellent conditions for insertion of LMA with
airway responses (1,2). Increasing the dose to prevent these may cause minimal hemodynamic disturbances, especially in ASA I-II patients.
hemodynamic disturbances. We conducted a study to find out the best More studies should be done to find out the proper dose of remifentanil
conditions for LMA insertion with two different doses of remifentanil for high-risk patients with unstable hemodynamia.
added to propofol and propofol administered alone. REFERENCES:
METHODS: Following hospital clinical research ethics committee 1)“Facilitation of laryngeal mask airway insertion”. Anesthesia 2001;
approval, 60 ASA I-II patients undergoing lower abdominal or urologic 56:879-905
operations were included in the randomized double-blind study. All 2)“The use of remifentanil to facilitate the insertion of the laryngeal
patients were premedicated with i.m. midazolam 0.2mg/kg and atropine mask airway”. Anesth Analg 2001; 93:359-62
0.5mg/kg. Patients received i.v. 0.25mcgr/kg remifentanil (Group R1),
0.50mcgr/kg remifentanil (Group R2) or normal saline (Group P) in
60s.Then following 20mg lidocaine, propofol 2mg/kg were
administered in R1 and R2 groups and 2.5mg/kg in P group. Ease of
insertion of LMA was graded by 3-point scale and airway quality at first
attempt was assessed either good or poor. Propofol 0.5mg/kg was added
in inability to insert the LMA. Maintenance of anesthesia was provided
with 50% N2O–O2 with 1.5-2% sevoflurane. Experience of the
anesthesiologist, number of attempts of LMA insertion, apnea time,
additional propofol requirement and heart rate, systolic (SBP) and
diastolic (DBP) blood pressures was recorded before premedication,
pre-induction (PI) and frequent intervals following the induction. Intra-
and postoperative side effects were also assessed.
RESULTS: There were no significant differences in demographic data
among the patients. Apnea time (mean ±SEM) was significantly shorter
in P group (34.09±5.5 s) compared to R1 (82.5±12.7s) and R2
(87.2±6.6s) groups (p<0.05). Heart rate, SBP and DBP measured 2min.
following the induction were significantly lower from baseline (PI)
values in the R2 group (p<0.05), but only 2 patients received atropin.
Ease of LMA insertion was found to be different between the groups
S-268 2003; 96; S-1–S-293
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SEVOFLURANE MAC AND CP50 FOR INSERTION OF those of CLMA.
PROSEAL VS CLASSIC LARYNGEAL MASK CONCLUSION: The sevoflurane requirement for insertion of PLMA
is higher than that required for CLMA.
AUTHORS: M. Kodaka, J. Uchida, A. Maeyama, I. Ishizuka, H.
Miyao REFERENCES:
(1) Anesthesiology 2002; 96: 289-95.
AFFILIATION: Saitama Medical Center/School, Kawagoe, Saitama
350-8550, Japan.
INTRODUCTION: A new laryngeal mask airway, ProSeal (PLMA)
has a modified cuff to improve the seal and a drainage tube to provide
access to the gastrointestinal tract. The PLMA is said to be more
difficult to insert than laryngeal mask airway Classic (CLMA) during
propofol anesthesia.(1) But there are no data using sevoflurane for
insertion of PLMA vs CLMA. We investigate sevoflurane MAC and
Cp50 for insertion of these LMAs.
METHODS: After written informed consent for the study was
obtained, 34 elective unpremedicated adult female patients (ASA I-II),
aged 20-50 were randomly assigned into PLMA ( n = 18 ) and CLMA (
n = 16 ) groups. Anesthesia was with sevoflurane in 100% oxygen.
After the predetermined target end-tidal sevoflurane had been
established and maintained more than 20 min using gas analyzer,
venous blood was sampled and LMA insertion was attempted without
neuromuscular blockade. The sevoflurane end-tidal concentration (ET
Sevo), starting at 2% for each patient, was decided by up and down
method with a 0.5% step. Data collection was continued until six
crossover points were obtained for each group and analyzed using
logistic regression to obtain the probability of no-movement versus ET
Sevo and Cp Sevo to obtain MACLMA and Cp50LMA levels (proprietry
software, JMP, SAS, Cary, NC) . Sevoflurane blood concentrations
were measured using gas chromatography.
RESULTS: The ET Sevo crossover point of PLMA and CLMA were
2.92 +/- 0.41 and 2.42 +/- 0.26 %, respectively ( p = 0.029; unpaired t-
test ). Logistic regression curves for probability of no-movement versus
Cp Sevo and ET Sevo are shown in the figure. According to the figure,
the values of MACPLMA and MACCLMA were 2.85 and 2.42%,
respectively. Cp50PLMA and Cp50CLMA were 79.3 and 65.7mcg/mL. Both
MACPLMA and Cp50PLMA were 17.8 and 20.7% higher respectively than
S-268
IS THE POST-TETANIC COUNT/TRAIN OF FOUR DISCUSSION: Cisatracurium, in doses of 0.15 mg/kg or greater, provide
RELATIONSHIP FOR INTENSE CISATRACURIUM-INDUCED acceptable intubating conditions by 2 minutes. The time to reappearence
NEUROMUSCULAR BLOCKADE DOSE-DEPENDANT? of T1 when a certain PTC is elicited during recovery from intense
cisatracurium-induced neuromuscular blockade is consistent and
AUTHORS: M. I. El-Orbany, N. J. Joseph, M. Salem unchanged regardless of the initial dose used. This allows better
AFFILIATION: Advocate Illinois Masonic Medical Center, Chicago, predictability in the block course when monitoring such degrees of
IL. neuromuscular blockade even when different doses are initially
administered.
INTRODUCTION: Recovery from intense neuromuscular blockade can REFERENCES:
be monitored by the post-tetanic count (PTC) and its relationship to the 1. Br J Anaesth 1987;59:1089;
first response (T1) of the train-of-four (TOF).1 Schultz et al., demonstrated 2. Acta Anaesthesiol Scand 2001;45:612;
that this relationship is altered depending upon the dose of rocuronium.2 3. Can J Anaesth 1996 ;43:925;
Cisatracurium, in doses ranging from 0.1 to 0.2 mg/kg (2 – 4 x ED95), has 4. Acta Anesthesiol Scand 1996;40:59-74.
previously been used to facilitate tracheal intubation.3 If this dose-
dependent relationship also exists for cisatracurium, the initial dose must Onset and PTC/T1Recovery Profile
be taken into consideration when using PTC to assess the degree of Cisatracurium Cisatracurium Cisatracurium Signifi-
neuromuscular blockade. The present study evaluates the PTC/T1 0.10 mg/kg 0.15 mg/kg 0.20 mg/kg cance P
relationship, onset time, and tracheal intubation conditions after (n=28) (n=29) (n=29) value
administeration of 0.1, 0.15 and 0.2 mg/kg cisatracurium. Onset
METHODS: After IRB approval, onset of neuromuscular blockade and 259.9 ± 21.0 207.7 ± 7.3 129.2 ± 5.7 < .0001
recovery profiles were studied using an acceleromyographic sensor in 86 Time (sec)
adult patients following either 0.1 (Group 1, n = 28), 0.15 (Group 2, n = Time to
29) or 0.2 (Group 3, n = 29) mg/kg cisatracurium. Intubation conditions 24.5 ± 3.0 35.6 ± 7.5 47.1 ± 3.5 < .0001
PTC1 (min)
were graded two minutes after cisatracurium administeration using
previously published criteria.4 Intubation conditions were considered Time to T1
34.9 ± 2.8 46.9 ± 6.5 59.7 ± 3.3 < .0001
clinically acceptable if they were Excellent or Good and unacceptable if (min)
Poor or Impossible. PTC1 -T1
RESULTS: Increasing the dose of cisatracurium produced faster onset
and prolonged the time to PTC1 and the time to T1. The time interval Interval 10.9 ± 1.0 11.3 ± 1.9 11.6 ± 1.7 NS
between a certain PTC and T1 reappearance and the number of post- (min)
tetanic responses elicited when T1 reappeared, however, were the same in PTC @ T1 8-9 8-9 8 -9 NS
the three groups (Table). Data in the table appears as mean ± standard
deviation or as counts. At 2 minutes, clinically acceptable intubating
conditions were obtained in all patients in Groups 2 and 3. Seven patients
recieving cisatracurium 0.1 mg/kg (Group 1) had unacceptable intubating
conditions (Poor = 6 and Impossible = 1) at two minutes.
2003; 96; S-1–S-293 S-270
S-269
OFFSET OF NEUROMUSCULAR BLOCK IS LONGER AT THE
ABDUCTING LARYNGEAL MUSCLE THAN AT THE
ADDUCTING LARYNGEAL MUSCLES IN HUMANS
AUTHORS: T. M. Hemmerling, D. Babin, F. Donati
AFFILIATION: University of Montreal, Montreal, PQ, Canada.
INTRODUCTION: This study investigates the onset and offset of
Neuromuscular block (NRM) at the adducting and abducting laryngeal
muscles in humans.
METHODS: After approval of the local Ethics Committee and
informed consent, 10 patients were included. Intubation was performed
without neuromuscular block using remifentanil/propofol and
maintained using remifentanil/sevoflurane. Two small condenser
microphones were inserted into the throat and placed lateral of the tube
near the vestibular fold to record the response of the adducting
laryngeal muscles (1) and behind the larynx to record the response of
the abducting laryngeal muscle. Percutaneous stimulation of the
laryngeal recurrent nerve was performed in routine fashion using
superficial electrodes placed over the thyroid notch. Train-of-four
stimulation was performed every 12 sec and supramaximal stimulation 1 ASA 2002, A-985
current determined. Mivacurium 0.1 mg/kg was injected IV. Onset, 2 Acta Anaesth Scand 2000; 44: 503-10
peak effect and offset of NMB was determined for both recording sites.
Data presented as mean (SD) and compared using t-test, P<0.05.
RESULTS: Onset, onset 90, and peak effect were 118 (34) s and 142
(20) s, 89 (38) s and 105 (26), and 71 (18) % and 84 (18) %,
respectively for the adducting laryngeal muscles and abducting
laryngeal muscle without being statistically different. Recovery is
presented in Figure 1, with offset of NMB at the abducting laryngeal
muscle being significantly longer than at the adducting laryngeal
muscles.
DISCUSSION: This is the first study in humans presenting a complete
onset and recovery profile of NMB at the adducting laryngeal muscles
and abducting laryngeal muscle. Offset of NMB after 0.1 mg/kg
mivacurium is 4-5 min longer at the abducting laryngeal muscle. This is
in contrast to previous findings in cats (2).
REFERENCES:
S-270
NEUROMUSCULAR EFFECTS OF ROCURONIUM IN REFERENCES:
PATIENTS WITH PARKINSON DISEASE 1)Ngai SH.Parkinsonism, levodopa, and anesthesia. Anesthesiology
1972 Sep 37:3 344-51
AUTHORS: Z. Salihoglu1, O. Demirkiran2, S. Demiroluk2, Y. Kose2, 2)VJ Collins, Principles of Anesthesiology, 1993:898.
G. Kaya2 3) Good clinical research practice (GCRP) in pharmacodynamic studies
AFFILIATION: 1Istanbul University, Cerrahpasa Tip Fakultesi, of neuromuscular blocking agents. Acta Anaesthesiol Scand 1996; 40:
Istanbul, Turkey, 2Istanbul Universitesi, Cerrahpasa Tip Fakultesi, 59-74.
Istanbul, Turkey.
Neuromuscular effects
INTRODUCTION: The effects of non-depolarising neuromuscular Groups Group Parkinson Group Control
blockers could change in Parkinson disease (1,2). In this study we Onset Time(sec) 59±7 64±15
compared the neuromuscular effects of rocuronium in patients with % 25 recovery (min) 42±11 39±14
Parkinson disease and normal patients. % 25-75 recovery (min) 12±4 9±7
METHODS: After ethics committee approval and written informed
consent from patients, 30 ASA II-III patients included in this study.
Patients with Parkinson disease were called in-Group Parkinson (n=15)
and patients with not any sign of Parkinson were called in-group
Control (n=15). Standard monitorization and anaesthesia induction
were used. Rocuronium (0.6 mg/kg) was given for neuromuscular
blockage. TOF Guard device (Organon tecnica, Belgium) was used for
neuromuscular monitorization. Orbicularis oculi muscle with TOF
(Train of Four) stimulation was used. The onset time of neuromuscular
blockage (sec) (OT), neuromuscular block’s recovery of % 25, %25-75
(recovery index) was recorded.
The intubating conditions were evaluated using a score described by
Viby-Mogensen and his colleagues (3). The intubation scores were
analysed using Chi-squared tests. The demographic data, and
neuromuscular effects of rocuronium were analysed using unpaired
Student’s t-test. P value smaller than <0.05 were considered statistically
significant.
RESULTS: There were no differences with respect to the age, sex,
weight, intubation condition and neuromuscular effects between two
groups.
DISCUSSION: The neuromuscular effects of rocuronium in Parkinson
patients were not differing in normal patients.
S-272 2003; 96; S-1–S-293
S-271
THE EFFECT OF DOSAGE AND TIMING OF NEOSTIGMINE T1 TOF TOF
RI TOF0.7-0.9
ADMINISTRATION ON REVERSAL OF VECURONIUM- recovery to recovery to recovery to
INDUCED NEUROMUSCULAR BLOKADE INA REPITITIVE (min) (min)
90% (min) 0.7 (min) 0.9 (min)
DOSE (VECURONIUM) MODE "zero-point" : the time when neostigmine injected
N20(n=10) 15±7** 9±3** @@ 17±7** 35±15 @@ ## 18±9 @@ ##
AUTHORS: Z. Lu, Y. Wang, B. Yu N40(n=10) 11±5 6±2 ## 14±6 ## 25±9 11±4
AFFILIATION: Ruijin Hospital, Shanghai, China. N60(n=10) 9±3 4±2 9±2 22±10 11±6
INTRODUCTION: To investigate the effect of dosage and timing of "zero-point":time when last dose of vecuronium administrated
neostigmine administration on reversal of vecuronium-induced G5min(n=10) 43±8 14±4 47±9 77±26 # 30±18
neuromuscular blokade in a repetitive dose (vecuronium) mode. GT1-1%(n=10) 37±14 5±3 * 37±15 51±21 14±8 @
METHODS: Seventy patients were included in this investigation. GT1-10%(n=10) 41±8 6±2 * 46±9 63±8 10±4 *
Thirty of them were randomized into three groups-- N20, N40and N60. GT1-25%(n=10) 43±13 3±1 * # & 45±14 57±23 12±11@
When the T1 recover to 10% after last dose of vecuronium
administrated, neostigmine 20ug/kg (N20), 40ug/kg (N40) or 60ug/kg The symbols in table means: ** P<0.01 vs N60 ; # # P<0.05 vs N60; @ @
(N60) were administrated. Then the time of T1 recovery to 90% (T90), P<0.05 vs N40 ; * P<0.01 vs G5min;@ P<0.05 vs G5min; & P<0.01 vs GT1-10%;
TOF recovery to 0.7 and 0.9 (TOF0.7 and TOF0.9) from neostigmine #
P<0.05 vs GT1-1% .
administrated, recovery index (RI) and time of TOF from 0.7 to DISCUSSION: In our study, we not only used the routine parameters
0.9(TOF0.7-0.9) were recorded. The other forty patients were randomized but also set a new parameter—TOF0.7-0.9. Because neuromuscular
to four groups-- G5min, GT1-1% , GT1-10% and GT1-25% . The neostigmine transmission was still impaired when TOFR was below 0.9, we think
40ug/kg was injected when 5min after last dose of vecuronium TOF0.7-0.9 can reflect the “unstable duration after extubation”. Our study
administrated (G5min ), T1 recovery to 1%( GT1-1% ), 10% (GT1-10% ) and shows the reversal of vecuronium-induced neuromuscular blokade was
25% (GT1-25% ) after last dose of vecuronium administrated. Then T1 potentiate when neostigmine increased from 20ug/kg to 40ug/kg. But if
recovery to 90% (T90’), TOF recovery to 0.7 and 0.9 (TOF0.7’ and neostigmine increased from 40ug/kg to 60ug/kg, only RI and TOF0.7
TOF0.9’) from last dose of vecuronium administrated, RI and TOF0.7-0.9 were decreased, 2 and 5min respectively, which haven’t clinical
were recorded. significance. In a single (vecuronium) mode, Bevan et al 1found the
RESULTS: There were no significant differences in the demographic timing of neostigmine administration didn’t have significant effect on
data (age, sex, weight and height ), surgical duration and vecuronium reversal of vecuronium-induced neuromuscular blokade if the time
magnitude among groups. All parameters were significantly prolonged when vecuronium administrated was used as a “zero-point”. In our
in N20 than N60. TOF0.9, RI and TOF0.7-0.9 were significantly prolonged in repetitive (vecuronium) mode, the recovery of vecuronium-induced
N20 than N40. TOF0.7 and RI were prolonged in N40 than N60. TOF0.7-0.9 neuromuscular blokade were faster if neostigmine was administrated
were significantly prolonged in G5min than other three groups. RI was when T1>1%.
significantly shorter in GT1-25% than other groups. TOF0.9’ was REFERENCES:
significantly prolonged in G5min than GT1-1%. Bevan JC, Coliins L, Fowler C, et al. Early and late reversal of
rocuronium and vecouronium with neostigmine in adults and children.
Anesth Analg 1999;89:333-9
S-272
NICOTINE AS A POTENTIAL ANTIEMETIC? cigarrette smoke, nicotine may have the most important antiemetic
effect.
AUTHORS: I. Acalovschi
AFFILIATION: University of Medicine and Pharmacy, Cluj-Napoca, REFERENCES:
Romania. 1) Ionescu D, Bedescu C, Maican D, Acalovschi I. Postoperative nausea
and vomiting. The influence of smoking. J Rom Anest Terapie Intensive
INTRODUCTION: In a previous research we found that smokers have 2002, 9;1:27-31
a significantly reduced incidence of PONV (1). The same results were 2) Cohen MM, Duncan PG, DeBoer DP, Tweed WA. The postoperative
published by Cohen et al in 1994 (2). Taking in consideration that interview: assesing risk factors for nausea and vomiting. Anaesthesia
smoke contains aproximately 4000 substances, the aim of this study was and Analgesia 1994; 78: 7-16
to see if nicotine, itself, has the same effects as the cigarette smoke. 3) Stoelting R. Pharmacology and Physiology in Anestetic Practice
METHODS: Following Ethics Comittee approval and after optaining Lippencott-Raven, 3rd ed, Philadelphia 1999, 527
informed written consent 75 pacients (ASA I and II) who underwent
laparoscopic cholecistectomy under general anaesthesia were divided in
3 groups: group 1 (n=25) of nonsmokers, group 2 (n=25) of
nonsmoking patients during the last five years witch received 16,6mg
NICORETTE-patch and group 3 (n=25) of patients with a history of
smoking. We decided to use 16,6 NICORETTE-patch after a pilot study
with 4,15mg, 8,3mg and 16,6mg of NICORETTE-patch. The general
anaesthesia was induced with thiopentone, fentanyl and atracurium and
maintained with halothane, fentanyl and atracurium . For the profilaxy
of PONV 1,25mg of droperidol were administrated to every patient
during induction. The patch was maintened 16 hours and removed after.
Postoperatively, nausea, retching, vomiting, the antiemetic medication
and the degree of maximum pain (on VAS) were assessed for 24 hours.
Statistical analysis used Chi-squared test and Student-T test for the
demographic data.
RESULTS: PONV occurred in 19 patients (76%) in group 1; 5 patients
(20%) in group 2 and 8 patients (32%) in group 3 (p1/2<0,05; p1/
3<0,05).
The degree of maximum pain, on VAS, was 5,33 in group 1; 4,04 in
group 2 and 2,8 in group 3 (p1/2<0,05; p1/3<0,05).
As side effects, 1 patient in group 2, developed dizziness, wich ceased
after NICORETTE removal.
DISCUSSION: It is generally accepted that nicotine has emetic
properties (3). In our study, application of Nicorette-patch significantly
reduced the incidence of PONV after laparoscopic cholecistectomy,
sugesting that among the numerous subatnces contained in the
2003; 96; S-1–S-293 S-274
S-273
COMPARISON OF ANALGESIC, ANTIEMETIC AND ANTI- in the MAC group (2%, 1 of 50). Thirty-one of 117 (26.5%) GA
HYPERTENSIVE MEDICATIONS IN THE POSTANESTHESIA patients in the PACU required more than 2 mg of IV morphine or more
CARE UNIT FOLLOWING USE OF REMIFENTANIL FOR than 100 g of IV fentanyl. This was also reflected in the fact that
MONITORED ANESTHESIA CARE VERSUS GENERAL significantly more patients in PACU following GA versus MAC were
treated for hypertension (11.96% vs 6.0%, respectively). Based on the
ANESTHESIA need for additional analgesic medications in the PACU, end of surgery
AUTHORS: A. Kovac, K. Picillo, C. Elliott analgesic pain preparation was considered to be correctly administered
AFFILIATION: University of Kansas Medical Center, Kansas City, for 100% of the remifentanil MAC patients and for 86 of 117 (73.5%)
of the remifentanil GA patients.
KS. CONCLUSION: Patients who received intraoperative remifentanil as a
INTRODUCTION: Remifentanil is an ultra-short acting opioid (half- primary analgesic component of balanced GA were more likely to
life=9 min) found useful for General anesthesia (GA) and monitored require treatment for postoperative pain, PONV and hypertension in the
anesthesia care (MAC). However, a potential drawback of PACU compared to remifentanil MAC patients. It appears that
remifentanil's short half-life can be pain, postoperative nausea and remifentanil GA patients would benefit receiving a long acting
vomiting (PONV), and hypertension in the postanesthesia care unit analgesic and an antiemetic at the end of the operative procedure before
(PACU). admission to the PACU.
Purpose: To evaluate correct intraoperative remifentanil use and end of
surgery analgesic preparation during MAC versus GA in relation to
pain control (analgesic use), PONV (antiemetic use), and treatment of
hypertension in the PACU.
METHODS: Following IRB exempted protocol, over a 5-month
period, 117 adult patients undergoing balanced GA with remifentanil
and 50 adult patients undergoing MAC with remifentanil were
retrospectively evaluated. In addition to demographic characteristics of
age, weight, and ASA physical class, data was collected for
intraoperative and PACU administration of antiemetics, analgesics
(opioids), and treatment of hypertension. PACU intravenous (IV)
administered opioids of fentanyl >100 g or morphine > 2 mg was
considered to be a failure of end-of-surgery analgesic preparation.
RESULTS: Demographic variables were similar between groups. The
most common MAC procedure was eye (cataracts) surgery, while the
most common GA procedures were orthopedic, gynecologic, and
general surgery. Significantly more patients having GA vs MAC
anesthesia were treated for hypertension (11.96% vs 6%), PONV
(14.5% vs 2.0%) and required more analgesic medications (42.7% vs
20.0%), respectively. The incidence of antiemetic use for PONV
following GA was 14.5% (17 of 117) which was significantly more than
S-274
THE PROPHYLACTIC EFFECT OF DEXAMETHASONE ON
POSTOPERATIVE SORE THROAT
AUTHORS: S. Park, K. Rhee, W. Ahn, J. Bahk, S. Do, K. Lee
AFFILIATION: Seoul National University Hospital, Seoul, Republic
of Korea.
INTRODUCTION:The aim of this study is to evaluate the
prophylactic effect of dexamethasone on postoperative sore throat.
METHODS:Two hundreds ten patients undergoing elective surgery
under general anesthesia were enrolled in this prospective, randomized,
double blined, placebo-controlled study and diveded three groups (n=70
in each three groups). Just after induction of anesthesia, Group 2 and 3
received 10mg and 20mg single dose of dexamethasone intravenously
and Group 1 received placebo-normal saline. Postoperative follow-up
was accomplished in all patients 2 hours and 24 hours after surgery
using VAS.
RESULTS:The incidence and severity of sore throat were lower in
Group 3 compared to Group 1.
DISCUSSION:Throat pain is one of most common complications after
endotracheal intubation and trachel mucosa damage occuring at the cuff
level is thought to an important cause. Dexamethasone is widely used as
an antiinflammatory agent in otolaryngology, has strong action of
relieving tissue edema and pain. So we hypothesized that
dexamethasone is effective to reduce postintubation airway edema and
symptoms and found 20mg of dexamethasone intravenous injection
could reduce postoperative throat pain.
S-276 2003; 96; S-1–S-293
S-275
THE EFFECTS OF SEDATIVE DOSES OF PROPOFOL OR
MIDAZOLAM AND HYPOXIA ON UPPER AIRWAY
OBSTRUCTION
AUTHORS: J. Norton, S. Karan, D. S. Ward, L. Palmer, W. A. Voter,
P. L. Bailey
AFFILIATION: University of Rochester Medical Center, Rochester,
NY.
INTRODUCTION: Respiratory compromise and hypoxia is often due
to upper airway obstruction (UAO) in sedated patients. We sought to
determine if propofol or midazolam produced different degrees of UAO
and whether hypoxia or gender influenced drug induced UAO.
METHODS: After IRB approval, informed consent was obtained from
healthy adult volunteers. Study design was double blind and
randomized. Standard monitors and an IV were used during the study.
Dynamic Negative Airway Pressures (DNAP) of 3, 6, 9, 12, 15, and 18
cm H2O were applied as previously described (1) to quantify each
individual‘s baseline propensity for UAO. Then, propofol or midazolam
was administered via a computer assisted controlled infusion to the
same clinical (Observer‘s Assessment of Alertness / Sedation Score of
2-3) and EEG (BIS value of 75 +/- 5) endpoints. During sedation DNAP
presented at the meeting will include data from additionally studied
was applied under hyperoxic (ET O2 = 150 mm Hg) and hypoxic (ET subjects.
O2 = 57 +/- 2 mm Hg) conditions. Sedation was stopped and DNAP
repeated 15 and 45 minutes later. UAO criteria included no airflow for DISCUSSION: Knowledge of the propensity for sedative drugs to
depress airway and ventilatory function, and of other factors that can
10 seconds or tidal volume <50 ml (measured via pneumotachograph) influence UAO would help clinicians select and deliver safer sedation
for 2 consecutive breath efforts. Respiratory inductive plethysmography
documented the absence of central apnea. Subjects returned between 7 in numerous settings. Our preliminary findings suggest that males tend
to have more UAO than females. This is similar to data with midazolam
and 45 days later to repeat the study with the second drug. sedation from Masuda et al. (2). Our data also suggests that hypoxia
RESULTS: Nine of 32 planned subjects (4 F, 5 M) have completed the
might diminish UAO during sedation with propofol but not with
study to date. With propofol, UAO occurred in 6 subjects during midazolam. We also found delayed UAO occurred after midazolam but
hyperoxia (1 F, 5 M) and in 2 subjects (0 F, 2 M) during hypoxia. With not propofol.
midazolam, UAO occurred in 7 subjects during hyperoxia (2 F, 5 M) REFERENCES:
and in 6 subjects (3 F, 3 M) during hypoxia. During recovery UAO
1. Anesthesiology 96:342-5, 2002. 2. Acta Anaesthesiol Scand 39:785-
occurred in 2 subjects (1F, 1M) at 15 minutes and 3 subjects (3 M) at 45 90, 1995
minutes after midazolam. No UAO occurred after stopping propofol
sedation. The chart shows values of DNAP causing UAO. Results This work was supported in part by a grant from the International
Anesthesia Research Society
S-276
A PRELIMINARY LOOK AT BETA2 ADRENERGIC include the polymorphisms of interest. These products are genotyped by
POLYMORPHISMS AND UTERINE QUIESENCE nucleotide extension in association with luciferase (Pyrosequencer).
RESULTS:
AUTHORS: S. Millar, J. V. Booth, H. A. Muir
AFFILIATION: Duke University Medical Center, Durham, NC. Polymorphism Frequency
Gln27Glu Thr163Ile
INTRODUCTION: Preterm delivery is defined as delivery of an infant Preterm Delivery n=9 Glu/Glu-5, Glu/Gly-0, Gln/Gln-4 Thr/Thr-9, Thr/Ile-0
after 20 weeks but prior to 37 weeks gestation. Despite improved Term Delivery n=4 Glu/Glu-2, Glu/Gly-0, Gln/Gln-2 Thr/Thr-4, Thr/Ile-0
antenatal care, the incidence of preterm delivery in the United States
increased from 9.5% in 1982 to approximately 11% in 1994.1 Preterm DISCUSSION: As yet numbers are insufficient to draw any
delivery is associated with a large proportion of perinatal complications conclusions, further recruitment and analysis is progressing.
and deaths. The mechanisms of the initiation of labor, and the means by REFERENCES:
which these are jumpstarted in preterm labor, have yet to be fully 1. Mon Vital Stat Rep, 44, S75, 1996.
understood. As well as the upregulation of an active system, labor may 2. Adv Exp Med Biol, 395, 435-451, 1995.
also involve the loss of quiescence. The downregulation of pathways 3. N Engl J Med, 341, 660-666.
that favor uterine quiescence by increasing cAMP formation, would 4. Pharmacology, 61, 167-173, 2000.
result in a relative dominance of stimulatory receptors that increase IP3/ Wholely supported by an IARS Clinical Scholar Grant.
Ca2+ availabilty.2,3 2-adrenoreceptor agonists have been used to suppress
labor in the preterm situation. This often limited grace period allows
time for transfer of the mother or the action of steroids to promote fetal
lung maturity. Myometrial dampening in response to agonists suggests
that this system may be involved in the maintenance of the continuing
pregnancy. There are four common 2 polymorphisms, Thr163Ile results
in decreased receptor/G protein coupling. The polymorphisms at
positions 16 and 27 alter agonist promoted receptor trafficking. In the 5‘
lead cistron polymorphism at position 19 leads to alteration in receptor
expression. These polymorphisms have been associated with
differences in disease severity and outcome, such as asthma and heart
failure.4 Our study looks at whether the presence of these
polymorphisms in the pregnant population, perhaps by compromising
quiescence, is associated with preterm labor
METHODS: Following IRB approval and written informed consent
200 women with preterm labor and delivery, and 200 women with term
labor and delivery will have been recruited to the study. Venous blood is
drawn, from which genomic DNA is derived using a standard kit
(Puregene). Biotinylated PCR products are generated covering the
regions 2-adrenoreceptor gene and its associated lead cistron that
Regional
REGIONAL
S-278 2003; 96; S-1–S-293
S-277
EFFICACY OF CERVICAL EPIDURAL STEROID demographic data between the groups. Significant improvement in VAS
INJECTIONS IN PATIENTS WITH AXIAL AND RADICULAR was noted 2 weeks, 6 months and 12 months after the last injection in
PAIN each individual group (Table). Some deterioration in axial neck pain
was observed over time, but the reduction in VAS score at 12 months
AUTHORS: P. Mohajer1, A. Biyani2, J. S. Kroin1, K. J. Tuman1, T. J. remained statistically significant. Improvement in arm pain was more
Lubenow1 sustained than neck pain, with VAS scores significantly lower for arm
AFFILIATION: 1Dept. of Anesthesiology, Rush Medical College, versus neck pain after 12 months.
Chicago, IL, 2Dept. of Orthopedic Surgery, Rush Medical College, DISCUSSION: The results from the current study show that patients
Chicago, IL. with axial and radicular symptoms respond favorably to CESI. The
improvement in neck VAS in patients with combined symptomatology
INTRODUCTION: Epidural steroid injections (ESI) are commonly is not as well sustained as for arm pain. We conclude that CESI remains
used for the treatment of axial and radicular pain of lumbar and cervical a useful tool in the armamentarium of physicians for management of
origin (1). While the literature is replete with studies that describe the cervical disorders, and may obviate the need for surgical intervention in
results of ESI for treatment of lumbar spinal disorders, few studies have a sizeable number of patients.
focused on the role of cervical ESI in non-operative management of
neck and arm pain (2,3). The purpose of this study was to evaluate the Axial Group Radicular Group Combined Group
efficacy of cervical ESI (CESI) in axial and radicular pain of cervical Neck VAS Arm VAS Neck VAS Arm VAS
origin, and to determine if different disease processes have different
Pre injection 7.35±0.88 5.60±2.49 6.79±1.59 6.56±1.66
treatment outcomes.
METHODS: Following IRB approval, 136 consecutive patients who 2 weeks 3.31±3.12 * 2.35±2.04 * 2.67±2.64 * 2.27±2.72 *
received CESI between January and December of 2000 were 6 months 3.50±2.85 * 2.35±2.19 * 3.38±2.75 * 2.35±2.90 *
retrospectively reviewed. From a comprehensive history, physical
examination and imaging studies, patients were divided into three 12 months 3.81±2.84 * 2.60±2.28 * 4.29±2.74 *,# 2.44±2.86 *
groups: axial pain, radicular pain, and combined axial and radicular * different from preinjection, p<0.05; # different from 2 weeks, p<0.05
pain. All patients received CESI with 80 mg of triamcinolone plus 4 ml References:
of preservative free saline. Second and third injections were (1) Surg Neurol 1996;46:455.
administered 2 weeks apart. Pain was assessed at the initial consultation (2) Spine 1993;18:730.
and at each subsequent visit utilizing the visual analog scale (VAS). (3) Arch Phys Med Rehabil 1994;75:342.
Patients were also evaluated at 2 weeks, 6 months and 12 months after (4) Clin J Pain 1989;5:143.
the final injection. Statistical evaluation was done using Kruskal-Wallis
test, Friedman’s test, and Wilcoxon’s signed-rank test.
RESULTS: Of the 136 patients reviewed, 38 patients were excluded
secondary to co-morbidity and previous surgery. Two patients were lost
to follow up. Five of the remaining 96 patients required surgical
intervention during the study period. The remaining 91 patients had:
axial pain (n=26), radicular pain (n=19), or combined axial and
radicular pain (n=46). There was no difference in the baseline
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PROSTAGLANDIN D2 AS A MARKER FOR IDENTIFICATION extrapolated onto the standard curve. Our results show a well-defined
OF CEREBROSPINAL FLUID DURING EPIDURAL correlation for the presence of PGD in CSF samples. Even at 1:10
ANESTHESIA: AN IN VITRO STUDY dilution of CSF with saline, anesthetic or serum, PGD was strongly
detected.
AUTHORS: R. Adsumelli, S. Kondabolu, J. Schabel, H. Benveniste, DISCUSSION: PGD was reliably identified in CSF when diluted with
P. Glass, S. Pentyala local anesthetics, saline and serum. Assay of PGD can evaluate the
AFFILIATION: State University of New York, Stony Brook, NY. presence of CSF and may be of great value to the clinician in safe
conduct of epidural anesthesia. Though this is not yet available as
INTRODUCTION: Reliable identification/exclusion of Cerebrospinal bedside test, the possibility of development of such test in near future is
fluid (CSF) is critical to avoid inadvertent subarachnoid injection of very likely; as such a test is of great value not only for anesthesiologists
local anesthetics during epidural anesthesia. When aspirate from the but also to ENT and neurosurgical specialists.
epidural catheters yield fluid, it could be CSF, local anesthetics, saline REFERENCES:
or interstitial fluid. Currently, none of the clinical tests used (Thiopental 1. Neurosci. Res. 21: 40-50, 1995.
precipitation, pH, glucose, temperature, Speed of flow from the 2. Ann. Otol. Rhinol. Laryngol. 1099-1102, 2000.
catheter) can reliably differentiate CSF from other substances in all
situations. For any test to be valid in the clinical setting, it should be
specific, sensitive, non-toxic, quick and easy enough to perform for
rapid bedside identification. Prostaglandin D2 synthase (PGDS) in brain
is produced in the choroid plexus, leptomeninges, and oligodendrocytes
of the central nervous system, and secreted into the CSF. PGDS
catalyzes the isomerization of Prostaglandin H2 to Prostaglandin D2
(PGD). PGD accumulates in CSF, where it is shown to be an
endogenous sleep-promoting substance (1). Both PGDS and PGD are
being tested as immunological markers for the detection of
cerebrospinal fluid traces (2). The aim of this study is to determine
whether these markers have any predictive value when CSF is
DILUTED with local anesthetics, saline and serum.
METHODS: After obtaining IRB approval and patient consent, CSF
was obtained from patients and analyzed for PGD. CSF (n=5) samples
were diluted with local anesthetic (Bupivacaine), normal saline and
serum in the ratios of 1:5 and 1:10. PGD levels in the CSF samples were
analyzed with a PGD-Methoxime (MOX) EIA Kit (Cayman Chemicals,
MI). This assay is based on the conversion of PGD to a stable
derivative, which is analyzed with antiserum specific for PGD-MOX.
RESULTS: Different concentrations of pure PGD-MOX conjugate
were analyzed by EIA and a standard curve was derived. PGD levels in
CSF and CSF with diluents were determined and the values were
2003; 96; S-1–S-293 S-280
S-279
A COMPARISON OF THE COMPLICATION RATE GA was lower with SCPB (18/3032 vs 127/7812; OR 2.74; P<0.001 2
ASSOCIATED WITH SUPERFICIAL VERSUS DEEP (OR test). Perhaps surprisingly, incidence of cardiac and neurological events
COMBINED) BLOCK FOR CAROTID ENDARTERECTOMY was also lower with SCPB (76/3032 vs 326/7812; OR 1.66; P<0.001 2
test).
AUTHORS: J. J. Pandit, R. Satya-Krishna, H. McQuay CONCLUSIONS: If SCPB and DCPB are equally effective (1,2), and
AFFILIATION: Nuffield Department of Anaesthetics, Oxford, United if as suggested, the injectate with SCPB enters the deep cervical space
Kingdom. (5), then there seems little advantage in performing a deep injection as
part of the block. The higher DCPB complication rate is probably
INTRODUCTION: Carotid endarterectomy is often performed awake related to deep needle placement close to vital structures in the neck.
under cervical plexus block using the patient‘s neurologic status as a REFERENCES:
monitor of cerebral perfusion, and may offer advantages over general 1. Anesth Analg 2000; 91: 781-786.
anesthesia (GA). Either superficial (SCPB) or deep (or superficial and 2. Anesthesiology 1998; 89: 907-12.
deep combined, DCPB) block may be used (1,2). SCPB may be safer 3. Br J Anaesth 1999; 83: 970-1.
than DCPB (3). However, the two blocks have been compared in only 4. Br J Anaesth 1997; 78: 642-51.
two small randomised studies (1,2). The purpose of this study was to 5. Br J Anaesth 2001; 87: 665P.
conduct a systematic review to assess the reported complication rates
associated with the use of each block.
METHODS: A supplemented Medline search yielded 86 relevant
publications in each of the following categories: randomised studies of
SCPB vs DCPB (2 papers); randomised SCPB vs GA (1 paper);
randomised DCPB vs GA (2 papers); non-randomised SCPB vs DCPB
(0 papers); non-randomised SCPB vs GA (5 papers); non-randomised
DCPB vs GA (21 papers); case series SCPB (11 papers); case series
DCPB (35 papers); case reports SCPB (0 papers); case reports DCPB
(11 papers). Each paper specified the total number of patients included
in the study (the denominator). We defined the complications
(numerators) in the following manner. A: any complication which was a
potential threat to life arising directly from placement of the block (eg,
intravascular, intrathecal injection, overdose, phrenic nerve paralysis);
B: number of patients converted to GA; C: any other serious
complications (eg, myocardial infarct, angina, stroke, transient
ischaemic attack). A was the main study end-point. Data were analysed
as previously described (4).
RESULTS: The 86 papers described 3032 SCPB and 7812 DCPB. The
incidence of complications in both groups was low. There were 0/3032
cases of serious complications related to the block in SCPB vs 73/7812
with DCPB (odds ratio OR 9.44; P<0.001 2 test; Fig. 1). Conversion to
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INTERSCALENE BLOCKS FOR OUTPATIENT SHOULDER scheduled outpatients had no problems related to the ISB on their post-
SURGERY: A REVIEW OF EXPERIENCE WITH A SINGLE op report by the surgeon, with intact neurovascular status. 2 patients had
SURGEON IN A COMMUNITY TEACHING HOSPITAL. residual numbness that resolved by their next visit (3 weeks later). One
patient had neck pain, which resolved with a trigger point injection.
AUTHORS: S. M. Parnass1, L. Wernikoff1, S. L. Blum1, M. Moric2, I. Other demographic and data results are in the table.
Kornblatt3 DISCUSSION: Our experience with ISB, in contrast to recent reports
AFFILIATION: 1Dept. of Anesthesiology, Rush North Shore Medical (1,2) has been uniformly well accepted, with low morbidity, and
Center, Skokie, IL, 2Dept. of Anesthesiology, Rush Medical College, excellent results. One factor not usually examined in reports on ISB, is
that of the surgeon’s experience. By analyzing data from a single
Chicago, IL, 3Dept. of Orthopedic Surgery, Rush North Shore Medical
surgeon’s practice, we eliminate a potentially confounding variable. We
Center, Skokie, IL. conclude that we have found ISB to be effective and safe in this setting,
INTRODUCTION: While interscalene blocks (ISB) for shoulder and without sequelae on long term follow up. It is our contention that
surgery have become routine in many institutions, recent articles on surgical experience, and surgeon acceptance of ISB, are important
safety and efficacy (1,2) have led to questions about the technique. To factors in determining whether or not to proceed with ISB for shoulder
decrease the number of variables, and for surgical consistency, we surgery.
retrospectively reviewed the charts of all outpatients receiving ISB and REFERENCES:
having shoulder surgery, by a single surgeon, over a 3-year period. (1) J Bone Joint Surg 2002; 84A: 775.
METHODS: The medical records of 93 consecutive outpatients (2) Anesthesiology 2001; 95: 875.
undergoing shoulder surgery by a single surgeon were reviewed. The
office records of each patient were also reviewed, as well as an Variable ISB
interview with the surgeon, for long- term follow-up. All ISB were Height 67.6 ± 3.8
performed with the use of a nerve stimulator and a standard insulated Weight 183.5 ± 36.1
blunt needle. A 1:1 mixture of alkalinized 2% lidocaine with
epinephrine and either 0.5% or 0.75% bupivacaine was utilized. Blocks Age 49.3 ± 14.4
were performed by either residents under the direct supervision of, or Procedure Duration 62.6 + 28.2
personally by, attending anesthesiologists. Adjunctive general
PACU Duration 71.8 ± 30.7
anesthesia (GA) was utilized in all cases. The need for immediate
parenteral narcotics in PACU, and a pain score (PS) > 3 in PACU or ASU Duration 129.7 ± 68.1
ASU was used to indicate an inadequate block.
RESULTS: Of 93 scheduled outpatients, 87 patients received
interscalene blocks. 8 patients met the criteria for inadequate block, for
a success rate of 91%. Only 2 patients required admission for pain
control. There were 3 other patients requiring admission, 1 for nausea,
and 2 for pulmonary/cardiac monitoring. 21/87 outpatients had
medication interventions for nausea in PACU (24%), and 22/82 (5
patients admitted) in 2nd stage recovery (27%). Only 5 patients in ASU
received medication for pain, and all were oral tablets. 84 of 87
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PERIBULBAR BLOCK FOR CATARACT SURGERY
AUTHORS: R. Gonzalez, C. Serrano, I. Gomez, E. Valdivieso
AFFILIATION: Hospital Clínico San Cecilio, Granada, Spain.
INTRODUCTION: Regional anaesthesia is the technique of choice for
the majority of patients undergoing cataract surgery. The purpose of this
study was to compare peribulbar block with ropivacaine 1% and
bupivacaine 0’5% + lignocaine 2%.
METHODS: Fifty patients (60 – 85 years old) were enrolled and
assigned randomly to two group. The group 1 (25 patients) received 8
ml of ropivacaine 1% + hialuronidase 150 IE and the group 2 (25
patients), 8 ml a mixture of bupivacaine 0’5% and lignocaine 2% +
hialuronidase 150 IE.
The following variables were evaluated:
1. Haemoynamic parameters: systolic and diastolic blood preasures and
heart rate.
2. Surgical conditions: very good, good, acceptable, bad and very bad.
3. Time of surgery.
4. Postoperative analgesia.
Data were analysed using Wilcoxon and Fisher tests.
RESULTS: No differences were found in haemodynamic variables,
surgical conditions, time of surgery and postoperative analgesia
between the two group.
DISCUSSION: Ropivacaine 1% is an effective alternative to
bupivacaine 0’5% for peribulbar anaesthesia, when combined with
lignocaine and hyaluronidase.
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EXPERIENCE REDUCES VARIABILITY IN DISCUSSION: There was considerably more variability in the point of
DETERMINATION OF POINT OF NEEDLE INSERTION IN needle insertion in the inexperienced group (Figure 1). This may help
PERIPHERAL NERVE BLOCKS explain the difficulty experience by some anesthesiologists in
performing peripheral nerve blocks. We conclude that with increasing
AUTHORS: S. A. Grant, D. Demeyts, D. S. Breslin, D. B. Macleod, experience there is reduced variability in determining point of needle
G. Martin, D. Hardman insertion using skin landmarks.
AFFILIATION: DUMC, Durham, NC. REFERENCES:
1. Regional Anesthesia and Pain Medicine 2002;27:245-7.
INTRODUCTION: Accurate identification of surface landmarks is 2. Raj P.P. Textbook of Regional Anesthesia 2002; p 365-7.
essential for successful performance of peripheral nerve blocks.1 We
hypothesized that there is a learning curve to successfully identifying
skin surface markings, which is vital in accurately identifying the point
of needle insertion. The variability between experienced and
inexperienced practitioners has not previously been studied.
METHOD: A male volunteer (90 kg, 178 cm, Body Mass Index=28)
was positioned in the left lateral knee-chest position. A large clear
adhesive dressing was placed over the volunteer’s back and buttock
area. All anesthesia residents and attendings in the OR on a random day
were giving a textbook description and photograph of how to perform a
posterior lumbar plexus block.2 They were asked to identify the point of
needle insertion by identifying the landmarks as described in the
textbook. X and Y coordinates were measured in millimeters for the
point of needle insertion. All skin markings were erased from the
dressing after each attempt. In addition the level of experience in
performing regional anesthesia was ascertained for each
anesthesiologist. Those who had performed more than 30 lumbar plexus
blocks in the past year were classified as experienced. The data were
analyzed using unpaired t tests with Welch’s correction and the F test
for equality of variance.
RESULTS: 37 anesthetists (16 experienced, 21 inexperienced) took
part in the study. The mean (SD) [Range] values for the X, Y
coordinates in millimeters were 81 (12)[62-108], 65 (12)[46-86] and 92
(24)[49-150], 63 (26)[0-131] in the experienced and inexperienced
groups respectively. While the differences in the mean values
approached significance (p=0.07) the variance between the 2 groups
differed significantly (p<0.01).
2003; 96; S-1–S-293 S-284
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TUMESCENT LOCAL ANESTHESIA DISCUSSION: Tumescent local anesthesia is a technique which
deserves further investigation as it appears to offer advantages such as
AUTHORS: J. H. Rao conservation of blood, avoiding of transfusion hazards and decreasing
AFFILIATION: Coimbatore Medical College Hospital, Coimbatore, operating time. It can be used alone or as an adjunct to any form of
India. anesthesia with very few contra-indications.
Literature on this technique is seen mainly pertaining to cosmetic
Tumescent local anesthetic (TLA) technique is a very useful way of plastic surgery and it is the endeavor of the author to evoke debate and
infiltration anesthesia. It was first described in December 1993 by a consensus on the use of this technique in routine surgical practice
plastic surgeon for use in Liposuction and other cosmetic procedures to
reduce blood loss , and uses higher doses of lignocaine per kilogram
body weight. In this study TLA has been tested in adjunct to other
forms of anesthesia and as a sole form of anesthesia to study tolerance
to the combination of drugs used, subjective assessment of blood loss
and to assess compatibility with other forms of anesthesia.
METHODS: In a period between, Sep.1998 to March .2000, diverse
cases which presented for surgery, in which normally blood loss is
anticipated were chosen for trial with this technique.
The compositon of the fluid that was used for injection was as follows
ØNormal saline /
Ø Ringer lactate - 500ml
Ø Lignocaine 2% - 25ml
Ø Adrenaline - 1ml (1:1000)
Ø 7.5% NaHCO3 - 10ml
Ø Hyaluronidase - 1500 iu(1 vial)
The volume of injection used was 10-15 ml/kg body weight using the
multiple injection technique. The tissue contact time was 10-15
minutes. 420 cases with diverse surgical procedures, emergency and
elective, adult and pediatric were studied. They included Post burns
contracture neck, Soft tissue swellings of the neck, Hemangiomas,
Craniotomy, laminectomy, Incisional and recurrent inguinal hernias and
Breast lesions. Informed consent was obtained for all patients
RESULTS: All patients tolerated the injection well. It could be
combined safely with other forms of anesthesia.Subjective assessment
revealed superior operating field in terms of clarity of tissue plane
dissection, scanty blood loss, reduced intra-operative and post operative
analgesic anesthetic requirements. No adverse outcome with reference
to its constituents or wound healing was recorded.
S-284
EFFECT OF SPINAL ANESTHESIA ON PROCESSED EEG in the PSA scores. These results indicate that spinal anesthesia
reduces the need for sedative agents in an elderly patient population.
AUTHORS: V. J. Kurup, M. Taboada, P. Atanassoff REFERENCES:
AFFILIATION: Yale University, New Haven, CT. 1. Br J Anaesth 81, 970-1,1998
2. J Clin Anesth 6 487-90, 1994
BACKGROUND: Centroneuraxis blockade has been known to have 3. Anesthesiology 93(3), 728-34, 2000
a sedative effect (1) thereby decreasing the need for inhalational and
intravenous anesthetic agents (2). The BIS monitor has been used
previously to quantify sedation during spinal anesthesia (3). In the
present study, quantification of sedation following spinal anesthesia
was investigated using a relatively new and more sophisticated
analysis of processed EEG (Patient State Analyzer, PSA 4000
monitor).
METHODS: Eighteen unsedated patients were scheduled to undergo
urologic and orthopedic surgeries under spinal anesthesia. All
received 1.5 ml (11.25 mg) of hyperbaric bupivacaine 0.75%
intrathecally. Monitoring included a 2-lead electrocardiogram, pulse-
oximetry, and non-invasive blood pressure (NIBP). A 4-lead EEG
tracing with two reference leads (PSA 4000) and Observer‘s
Assessment of Alertness/Sedation Scale (OAAS) score were obtained
to evaluate the depth of sedation. Baseline recordings were obtained
for a period of 3 min prior to surgery and every 2 minutes during the
surgical procedure. Data are expressed as mean±SD and were
evaluated by Wilcoxon signed rank test for non-parametric data.
RESULTS: The patients were 69±16 years of age. Surgical
procedures lasted 65±34 min. Sedation scores measured by PSA
decreased from previously 98±2 to 76±10 at 33±15 min into the spinal
anesthetic (p<0.05). OAAS decreased from formerly 5 to 4±1 at the
time of the lowest PSA scores (p=ns). Following spinal anesthesia to a
dermatomal level of T 8±2, the systolic/diastolic BP decreased from
baseline 143±20/82±11 mmHg to 104±11/62±10 mmHg at the time of
the lowest PSA score (p<0.05).
DISCUSSION: In this elderly patient population, spinal anesthesia
induced changes in the processed EEG with reduction in PSA scores
without affecting substantially OAAS. The reduction in systolic and
diastolic blood pressures following spinal anesthesia was within the
range of cerebral autoregulation. Most likely, the reduction in afferent
input to the CNS due to spinal anaesthesia contributed to the reduction
S-286 2003; 96; S-1–S-293
S-285
SPINAL CHLOROPROCAINE 150) minutes, respectively. The thigh tourniquet was tolerated 63 + 21
(range: 28 - 107) minutes. Full lower extremity muscle strength returns
AUTHORS: K. N. Smith, D. J. Kopacz, S. B. McDonald at 110 + 35 (range: 70 - 190) minutes. Time to complete sensory
AFFILIATION: Virginia Mason Medical Center, Seattle, WA. regression (and the ability to ambulate) averages 142 + 30 (range: 100 -
200) minutes.
INTRODUCTION: The choice of local anesthetic agent for spinal DISCUSSION: Initial results suggest that hyperbaric spinal 2-
anesthesia in the ambulatory surgery patient remains a problem. chloroprocaine may have an anesthetic profile appropriate for use in the
Lidocaine is plagued by the frequent symptoms of transient radicular surgical outpatient. As some of the spinal anesthetics attained high
irritation (TRI). Bupivacaine often produces an excessively long block, dermatome levels (C5), it will not be necessary to study the previously
even in markedly reduced doses. Chloroprocaine is avoided because of planned higher dose (75 mg), but the investigation of a lower dose (30
reports in the 1980s of neurotoxicity after unintentional intrathecal mg) is warranted.
injection of large volumes of preservative-containing solutions intended REFERENCES:
for the epidural space (1). However, a preservative-free formulation of 1) Anesth Analg 1982; 61: 158-9.
2-chloroprocaine (Nesacaine-MPF, AstraZeneca LLC) is now available. 2) Anesthesiology 1952; 13: 287-96.
When first introduced in 1951, Foldes described the successful use of 3) Anesth Analg 2002; 94: 188-93.
preservative-free chloroprocaine for spinal anesthesia in 214 patients
(2). As chloroprocaine is known to be of shorter duration than lidocaine,
we investigate the dose-response effects of the new preservative-free
formulation of 2-chloroprocaine in a human volunteer model, as a
possible alternative for outpatient spinal anesthesia.
METHODS: This randomized, blinded study is designed to initially
investigate 2 doses of hyperbaric 2-chloroprocaine (45 and 60 mg), with
or without the addition of 0.2 mg epinephrine, using a previously
described cross-over methodology (pinprick anesthesia, tolerance to
transcutaneous nerve stimulation and thigh tourniquet, and motor
strength assessments) in 12 volunteers (3). If the duration or density of
anesthesia is not clinically suitable, an additional 6 volunteers will
receive 75 mg. 2-chloroprocaine, with or without epinephrine.
RESULTS: As this investigation is ongoing and still blinded, the
preliminary combined results from the first 14 spinal anesthetics, in
which volunteers received either 45 or 60 mg of 2-chloroprocaine (with
or without 0.2 mg epinephrine), are presented. Successful spinal
anesthesia was attained in all subjects, with complete return of
neurologic function within 200 minutes of injection. No signs or
symptoms of neurotoxicity have been observed. No symptoms of TRI
have been reported. Peak block height averaged T4 (range C5 – T11,
Figure 1). Regression of 2 segments and to the L1 dermatome averaged
49 + 11 (mean + SD)(range: 35 – 80) minutes, and 91 + 24 (range: 50 –
S-286
BLOOD VOLUME INCREASE BY HYPERTONIC SALINE groups did not differ significantly on Na or Hg. Time for prehydration
ADMINISTRATION PREVENTS SYSTEMIC HYPOTENSION was significantly lower in HS group than in the NS group (5.0 vs. 25.5
AFTER SPINAL ANESTHESIA min, 95% CI 19 to 23 min, P<0.001).
CONCLUSION: Our results indicate that a single bolus dose of NaCl
AUTHORS: N. Tcherven1, D. Yondov2, S. Worley1, J. Tetzlaff1 10% administered preoperatively might be a safe alternative to a
AFFILIATION: 1Cleveland Clinic Foundation, Cleveland, OH, normoosmolar crystalloid. HS was not significantly less effective than
2
Higher Medical Institute, Plovdiv, Bulgaria. much larger volumes of NS in maintaining arterial blood pressure. HS
infusion requires significantly less time for prehydration. Although the
INTRODUCTION: Indications for hypertonic NaCl infusion for clinical relevance of these results in patients with different co-
maintenance of arterial hypotension (AH) after subarachnoid anesthesia morbidities should be established in future studies, application of HS
(SA) are still being investigated.1,2 We examined the effect of NaCl 10% should be considered as a practical option to the standard prehydration
on blood volume and resultant arterial blood pressure changes in practices.
clinical conditions. REFERENCES:
MATERIALS AND METHODS: In HS group (n=30) NaCl 10%, 1 Ann Fr Anesth Reanim 1999;18(6):631-5
ml/kg/bw was administered before and after SA. The NS group (n=32) Anesth Analg. 2000; 91: 1461-5
was given NaCl 0.9 % 5-7 ml/kg/bw. Administration of NS continued Surgery 1962; 51:224-32
up to a total of 1500 ml. AH was defined as a decrease in MAP of more
than 30%. Blood pressures were measured for an hour in 5 min.
intervals. Changes in blood volume were determined according to
unicompartmental model.3 Other parameters monitored included serum
Na, K, Hg, time for prehydration and mean corpuscular volume (MCV)
of RBC. Treatment groups were compared using repeated measures
mixed models, which included main effects for baseline values and
treatment group and a cubic polynomial for time. Wilcoxon rank-sum
test was utilized for blood volume, retained volume, MCV, Na, and Hg.
Results are presented as medians and 95% confidence intervals
(95%CI) with significance level 0.05.
RESULTS: Treatment group was not a significant predictor of AH,
MAP, SBP, or DBP. The NS group had significantly larger increases in
blood volume during surgery than did the HS group (0.83 L vs. 0.33 L,
95% CI 0.08 to 0.71, P=0.011). Retained volume of HS was higher in
the HS group than in the NS group (217% vs. 55%, P=0.002). In the NS
group, MCV increased significantly during surgery (0.8 fL, 95% CI 0.1
to 1.0, P=0.008). A transient increase of serum Na was observed after
HS (7.5 mmol/L, 95% CI 4.0 to 11.0 mmol/L, P<0.001). Hemodilution
was observed in the HS group at 10 min. post SA (Hg, NS 14.2 g/dL,
HS 13.2 g/dL, P<0.001). At the end of the observation period, treatment
2003; 96; S-1–S-293 S-288
S-287
CONTINUOUS SPINAL ANESTHESIA WITH TWO
DIFFERENT CATHETERS IN ELDERLY
AUTHORS: A. Yilmazlar1, O. Kutlay2, O. Ilgaz2
AFFILIATION: 1Uludag University, Bursa, Turkey, 2
Uludag
INTRODUCTION:The purpose of this retrospective study was to
compare the technical problems in elderly patients after CSA using
catheter in side the needle (CIN) and the catheter over the needle (CON)
techniques.
MATERIAL AND METHOD: Forty elderly patients (ASA I-II)
ranging from 80-92 yrs old and undergoing hemiarthroplasty surgery
were assigned to CIN (n:20) and CON (n:20) group. Technical
difficulties of both techniques , side-effects and complications were
recorded.
RESULTS: In CON group; inadequate anesthesia, difficulty threating
catheter and poor cerebro-spinal fluid (CSF) flow was seen in 1,2, and 3
patients, respectively.So that; technical problems occured more frequent
in CON group (p< 0.05) but none in CIN group. No neurologic sequelae
and PDPH occured in both groups. The catheter functions and
postoperative results were similar with the two catheters.
CONCLUSION: CSA using catheter in side the needle technically
more easy than using the catheter over the needle and also there are no
differency with side- effects and complications (PDPH etc.) between
two different catheters in the elderly.
REFERENCES:
1) Puollakka R,et al.Comparison of three catheter sets for continuous
spinal anesthesia in patients undergoing total hip or knee arthroplasty.
Reg Anesth Pain Med 25;584-90:2000.
S-288
CONTINUOUS SPINAL ANESTHESIA WITH HYPERBARIC
BUPIVACAINE 3MG+ FENTANYL 10µG FOR HEMI-
ARTHROPLASTY IN THE ELDERLY
AUTHORS: A. Yilmazlar1, O. Kutlay2, O. Ilgaz2
AFFILIATION: 1Uludag University, Bursa, Turkey, 2
Uludag
INTRODUCTION: Three mg of hyperbaric bupivacaine + 10 µg
fentanyl produces a reliable spinal anesthesia(1,2). We hypothetized
that continuous spinal anesthesia with same dose agents will allow
hemiarthroplasty surgery in the elderly.
MATERIAL AND METHOD: Thirty ASA II-III patients,all older
than 85 yr who underwent hemiarthtroplasty were randomly assigned to
receive either 5 mg hyperbaric bupivacaine (Group B)(n:15) or 3 mg
hyperbaric bupivacaine + 10 µg fentanyl (Group BF)(n:15). We used “
catheter over needle continuos spinal anesthesia technique” for all
cases. The sensory level was assesed by the pinprick test. To maintain
mean arterial pressure within %25 of initial value, incremental doses of
ephedrine were given iv.
RESULTS: Twelve patients (80.0%) in Group B and one patient (6.6%)
in GroupBF required fractional reinjection of local anesthetic via spinal
catheter(p<0.001). More patients in the Group B(13 vs 2)(86.6% vs
13.3%)(p<0.001) required ephedrine. All patients in both groups
developed a level of anesthesia not higher than T6.
CONCLUSION: Three mg of hyperbaric bupivacaine + 10 µg fentanyl
produces a reliable continuous spinal anesthesia for hemiarthropasty in
elderly.
REFERENCES:
1)Valanne J et al.Intrthecal hyperbaric bupivacaine 3mg+fentanyl 10µg
for knee arthroscopy with tourniquet.Eur J Anaesth 19(Suppl):104,2002
2)Yilmazlar A et al.Continuos spinal anaesthesia versus single dose
spinal anaesthesia in elderly patients. .Eur J Anaesth
19(Suppl):105,2002
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S-289
INFLUENCE OF THE PATIENTS POSITION DURING a. Also better tolerated. b. In three of the cases reported in group A, the
INDUCTION OF COMBINED SPINAL-EPIDURAL catheter could not be left due to spinal blockade in the 5 cases of group
ANESTHESIA FOR TOTAL KNEE ARTROPLASTY B even if the spinal blockade appeared the correct placement of the
epidural catheter could be done.
AUTHORS: R. Gonzalez, C. Serrano, A. Cañas, J. Prieto DISCUSSION: In the Combined Spinal-Epidural (CSE) anesthetic
AFFILIATION: Hospital Clinico San Cecilio, Granada, Spain. technique, the lateral decubitus position presents less incidence and
duration of hypotension, higher tolerance of vomiting sensation and less
INTRODUCTION: We wish to compare the anesthetic protocol for failure of the technique while puncturing a vessel with the catheter.
total knee artroplasty done by combined spinal-epidural anesthesia just
changing the patient position while puncture.
METHODS: 40 patients of both sexes over 60 years were evaluated
during the intervention. All of them were randomly allocated in two
groups: group A (n=20) and group B(n=20). The patients in group A
were sat when they had the puncture and the insertion of the epidural
catheter. Patients in group B went to the same anesthetic procidia, in
lateral decubitus on the side of the knee that was going to be operated.
All the patients, 20 minutes before the surgery were administered 500cc
of lactated Ringers's solution. All of them were administered
bupivacaíne 0,5%, 10 mg. + fentanyl 20 g by spinal application, leaving
the epidural catheter for post surgery pain control. The cardiac
frequency, arterial pressure, oxygen saturation, need for efedrin
administration, vomit sensation, vomits, sweat, if there was any
punction by the catether of blood vessels were evaluated. It was also
evaluated patient’s sensation of comfort or disconfort before starting
surgery.
RESULTS:
Group A Group B
Symptom
(Sitting position) (Lateral decubitus)
Hypotension 54% 38%
Sweating and vomiting sensation 47% 32%a
Efedrin needed for hypotension control 35mg +/-8mg 20mg+/-5mg
Duration of hypotension 7min+/-3 4min+/-2
Vessels punctured 6b 5b
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THE EFFECTS OF EPIDURAL ANESTHESIA WITH 0.25 % nitric oxyde (pg/ml) and interleukin levels(mikromol/L)
BUPIVACAINE ON THE NEUROENDOCRINE RESPONSE TO
Periods 0. hour 2. hour 6. hour 24. hour
MAJOR ABDOMINAL SURGERY
Group G: IL-6 15.0±3.4 46.9±8.3 57.0±8.0 46.1±8.2
AUTHORS: Z. Salihoglu1, F. Altintas2, I. Ozdilmac2, S. I. Demiroluk2, Group G-Epi: NO 17.4±3.5 35.3±7.2 45.2±5.6 35.5±4.8
H. Uzun3
Group G: NO 22.95±3 31±3 34.3±4 29.95±4
AFFILIATION: 1Istanbul University, Cerrahpasa Tip Fakultesi,
Istanbul, Turkey, 2Istanbul University, Istanbul, Turkey, 3Istanbul Group G-Epi: NO 21. 5±4 33.2±3 30.1±2 27.2±3
University Biyokimya Bolumu, Istanbul, Turkey.
INTRODUCTION: The simultaneous administration of epidural local
anesthetics with general anesthetics is frequently used in major
abdominal surgery (1,2).To determine the ability of epidural anesthesia
with 0.25 % bupivacaine to attenuate the surgical stress response.
METHODS: Thirty ASA I-II patients undergoing major abdominal
surgery were randomized to receive either general anesthesia (n = 15) or
combined regional/general anesthesia with intraoperative epidural
catheter anesthesia using bupivacaine to the T10 dermatome level (n =
15). The stress response was quantitated by blinded measurement of
baseline and postoperative (0, 2, 6, 24 hours) serum cortisol, glucose,
interleukin (IL)-6, C-reactive protein (CRP), malonildialdehide (MDA),
nitric oxyde (NO), super oxyde dismutase (SOD).
RESULTS: IL-6 and NO levels (table I) were less predictable and
undetectable in the Group G-Epi (p<0.05). There was no difference in
any of the stress response indices between those patients receiving
patient-controlled or epidural catheter anesthesia.
Discussion:The neuroendocrine response to major surgical stress is
propagated normally despite epidural blockade.
REFERENCES:
1) Use of epidural anesthesia and spontaneous ventilation during
transabdominal colon and rectal procedures in selected high-risk patient
groups. Dis Colon Rectum 1997 ; 40: 339-43.
2) Influence of postoperative epidural analgesia with bupivacaine on
intestinal motility, transit time, and anastomotic healing. World J Surg
2002; 26: 303-6.
2003; 96; S-1–S-293 S-292
S-291
THE INFLUENCE OF EPIDURAL ANESTHESIA ON THE tracheal intubation, but did not in the group E (table).
INTRAVENOUS INDUCTION WITH PROPOFOL DISCUSSION: Epidural anesthesia shortens the time until LOC with
propofol and diminishes MBP and HR changes caused by tracheal
AUTHORS: T. Nakatani, H. Kushizaki, K. Kanata, H. Hiruta, Y. Saito intubation. The results suggest that the epidural anesthesia combined
AFFILIATION: Shimane medical university, Izumo, Japan. with the propofol anesthesia may contribute the rapid induction with
little circulatory changes caused by tracheal intubation.
INTRODUCTION: Epidural anesthesia has been reported to the REFERENCES:
decrease requirements for general anesthesia (1), suggesting the general (1) Anesthesiology 1999; 91:1687-92
anesthetic effects of epidural anesthesia. Therefore, epidural anesthesia
possibly modulates the intravenous induction with propofol. Epidural Table: circulatory changes following induction with propofol
anesthesia and propofol intravenous anesthesia have circulatory (*P<0.05 vs. baseline, †P<0.05 vs. 6min)
interactions, which may affect the circulatory changes during the
anesthesia induction. There is little information about the influence of baseline 4min 6min post intubation
epidural anesthesia on the propofol induction using target controlled MBP (mmHg)
infusion (TCI). This study was designed to assess the induction time
and circulatory changes on the intravenous induction with propofol Group E 90.6±14 62.9±11* 57.3±9* 77.4±18
following the epidural anesthesia. Group C 98.3±13 78.1±8 75.1±8 127.5±19†
METHODS: After obtaining IRB approval, twenty ASA status I-II HR (/min)
patients received epidural and general anesthesia. Ten patients (Group
E) were received 3mg/kg of 1.5% lidocaine and another patients (Group Group E 73.2±16 61.1±11 60.9±11 74.8±8
C) received the same volume of saline via thoracic epidural catheter. All Group C 73.8±11 70.0±10 69.8±11 91.4±13†
patients were induced general anesthesia with propofol using TCI
15minutes after epidural injection. The target concentration of propofol Mean ± SD
was set on 3g/ml. Loss of consciousness (LOC) was assessed the time
to drop a holding syringe. Bispectral Index (BIS) scores and mean
arterial pressure (MAP) and heart rate (HR) were measured after
induction following baseline measurement with the interval of 5
seconds, 2 minutes and 2minutes, respectively. Statistical differences
were analyzed by Mann-Whitney U-tests or non-paired t tests or one-
factor ANOVA with Scheffe‘s S procedure. P value less than 0.05 was
considered as statistically significant.
RESULTS: There were no differences in demographic data between
groups. The time until LOC assessed by dropping the syringe was
significantly shorter in Group E compared with group C (mean 84s ± 21
vs. mean 143s ± 61). BIS scores in the group E tended to decrease more
rapidly than that in the group C. The decreases in MAP were
significantly greater in the group E during induction of general
anesthesia. MAP and HR increased significantly in the group C after
S-292
AN ANALYSIS OF CLINICAL OUTCOMES WITH EPIDURAL were significant predictors of less pain on day 1 (p<0.01), but catheter
ANALGESIA IN ADULT POST-SURGICAL PATIENTS level and increase infusion rate accounted for lower pain scores on day
2 (p<0.01). Recursive partitioning confirmed that adequacy of pain
AUTHORS: P. M. McQuillan, C. M. Gelnett, R. C. Polomano, J. E. management in the PACU was the principal determinant of pain on
Chadwick, R. M. Flatto, F. K. Orkin POD 1. Overall, rates of infection and new neurological deficits (e.g.,
AFFILIATION: Penn State Milton S. Hershey Medical Center, Penn weakness, numbness) were 0.2% and headache 0.6%.
State College of Medicine, Hershey, PA. DISCUSSION: Adequacy of pain management in the PACU, age, and
catheter site predict postoperative pain levels, whereas epidural solution
INTRODUCTION: While effectiveness and safety of postoperative influences the occurrence of side effects. Practice pattern variation does
epidural analgesia have been demonstrated with prospective and affect clinical outcomes for patients receiving continuous postoperative
retrospective reviews,1 few studies explore the influence of practice epidural analgesia. Studies with larger numbers of subjects may reveal
pattern on clinical outcome. Here, we present an analysis of epidural measurable differences in other adverse effects with epidural solutions.
analgesia-related outcomes to examine how practice variables (e.g., REFERENCES:
1
catheter placement, combinations of epidural solutions) affect pain and Wheeler M, et al.: J of Pain, 3(3):159-180, 2002.
adverse effects.
METHODS: We tracked analgesia-related outcomes in 980 Key: FB - Fentanyl 4 mcg/mL + Bupivacaine 0.0625%; BF - Fentanyl 4
consecutive patients receiving epidural infusions for postoperative pain mcg/mL + Bupivacaine 0.125%; BH - Bupivacaine 0.125% +
control over 18 months. Information was collected on pain diagnosis, Hydromorphone 15 mcg/mL; PB - Bupivacaine 0.1%
surgical service, type of anesthesia, catheter level, and epidural
solution. Serial measurements of pain severity, sedation, nausea/
vomiting (N/V), pruritis, motor impairment, urinary retention, and
respiratory depression were recorded for duration of therapy. Data were
analyzed using descriptive, parametric and nonparametric and
correlation statistics, and recursive partitioning.
RESULTS: Table 1 shows the summary statistics for the sample and
the most common epidural solution combinations. No differences in
severity of adverse effects (sedation, N/V, pruritis, motor impairment)
were found by epidural solution in the PACU. Increased severity of
nausea and vomiting occurred with solution BH compared to BF
(p<0.01) and PB (p<0.05) on postoperative day (POD) 1. Pruritis was
worse with BF compared to FB (p<0.05) and PB (p<0.01), and BH
compared to PB (p<0.01) on POD 2. The incidence of respiratory
depression, rate <10/min, for the entire sample was 0.5% in the PACU,
0.1% on day 1 and 0.2% on POD 2, limiting the ability to detect
meaningful differences by epidural solution. Mild local anesthetic side
effects (e.g., metallic taste, tinnitus) were observed in 0.4% of patients
on POD 1 and 0.3% on POD 2. Higher catheter level and younger age
2003; 96; S-1–S-293
S-293
OUTCOMES AFTER ACL RECONSTRUCTION: THE EFFECT physical component summary and the Knee Outcome Survey Sports
OF FEMORAL NERVE BLOCK ANALGESIA Activity Scale. There were no significant differences with respect to
cumulative opioid requirements during the first 4 postoperative days,
AUTHORS: B. A. Williams, M. T. Vogt, C. M. Figallo, K. A. Francis, any other verbal pain scores during the first 3 weeks, or other
M. L. Kentor, C. D. Harner measurable physical function outcomes (by self-report or in the
AFFILIATION: University of Pittsburgh, Pittsburgh, PA. physical therapy laboratory).
DISCUSSION: Reflex neuromuscular inhibition is a theoretical risk of
INTRODUCTION: We are studying the influence of nerve block pain temporarily abolishing afferent discharge in a peripheral nerve. Reflex
management on outcomes after outpatient anterior cruciate ligament inhibition can lead to muscle weakness, atrophy, immobilization, and
(ACL) reconstruction. Our hypothesis is that patients undergoing nerve joint damage, [2] all of which may lead to gait abnormalities and
block analgesia (versus not) will manifest better self-reported recovery impede physical therapy progress. These may occur, in theory, despite
outcomes, physical function outcomes, and objective measures of satisfactory pain relief and patient-reported outcome survey scores. At
neuromuscular function. The specific aim is to determine the quality of this time, there is no evidence to indicate any trends toward these
immediate recovery (from anesthesia) and extent of reported pain, and adverse sequelae, but further enrollment is required.
to determine whether the use of nerve block analgesia is associated with REFERENCES:
impairment of quadriceps femoris torque output. Comparisons were [1]BJA 84:11-15, 2000
performed to determine the better dosing strategy for these patients of [2]Rheum Dis Clin North Am 25:283-298, 1999.
the following 3 treatment groups: (i) single-shot femoral nerve block
and nerve sheath infusion with levo-bupivacaine, (ii) single-shot block Supported by IARS Clinical Scholar Award and by NIH/NIAMS
with levo-bupivacaine and infusion with saline, and (iii) single-shot K23AR47631.
sham block and infusion with saline.
METHODS: Consented patients (n=62) undergoing ACL Self-Reported Outcomes after ACL Reconstruction Based On
reconstruction received conventional spinal anesthesia and were Nerve Block Treatment Group
randomized to receive one of the 3 nerve block treatments. Patient- POD#4 POD#4 POD#4 Wk#12 Wk#12
reported recovery outcomes throughout the first week after surgery Treatment
VPS with QoR40 SF-8 SF36 KOS
were compared across treatment groups using validated health status Group
measures suitable for daily assessment (Verbal Pain Score, SF-8, and Movement Total Score PCS PCS SAS
the Quality of Recovery [QoR-40] Score [1]). One and 3 weeks after A 3.0 176 28 41 43
surgery, goniometry with electromyography (EMG) data were collected
B 4.0 183 34 48 59
to test postoperative range of motion in extension, and to determine
quadriceps femoris torque output. Assessments at 3, 7, and 12 weeks C 2.0 189 37 49 74
were performed with 2 validated patient-reported outcome measures Sample Size n=58 n=55 n=57 n=38 n=26
(SF-36, Knee Outcome Survey).
RESULTS: Verbal pain scores with activity, QoR-40, and SF-8 P value 0.015 0.032 0.004 0.019 0.016
physical component summary scores were significantly different
between treatment groups on POD#4. At 12 weeks, there were
significant differences between groups with respect to the SF-36
ANESTH ANALG AUTHOR INDEX S-294
2003; 96; S-1–S-293
Author Index
Abadir AR, see Michael R CONSUMPTION IN PATIENTS FOLLOWING Bolis RS, LeDez k, WARNING SYSTEM TO
see Michael R UNILATERAL MANDIBULAR THIRD DETECT CONTACT WITH UPPER TEETH
Abdullah R, see Hilmi IA MOLAR EXTRACTION UNDER LOCAL DURING LARYNGOSCOPY, S-159
Acalovschi I, NICOTINE AS A POTENTIAL ANESTHESIA, S-197 Bone HG, see Westphal M
ANTIEMETIC?, S-272 Aouad R, see Taboada M see Westphal M
Adachi N, see Mitsuyo T Aoyama Y, see Ishikawa A Bonnel M, see Urdaneta F
Aden U, see Kopf A Apfel CC, see Kranke P Booke M, see Westphal M
Adsumelli R, Kondabolu S, Schabel J, Benveniste H, Arai T, see Mitsuyo T see Westphal M
Glass P, Pentyala S, PROSTAGLANDIN D2 AS see Mori T Boone J, see Chaudhuri K
A MARKER FOR IDENTIFICATION OF Arron BL, see Weaver JM Booth JV, see Millar S
CEREBROSPINAL FLUID DURING Arya VK, see Bagchi A Borg UR, see Lichtenthal PR
EPIDURAL ANESTHESIA: AN IN VITRO Asada A, see Kariya N Brandwjik M, see Cook RI
STUDY, S-278 Atanassoff P, see Kurup VJ Breen PH, see Rosenbaum A
Agarwala AV, Backus A, SURVEY OF PERSONAL Atanassoff PG, see Taboada M see Rosenbaum A
DIGITAL ASSISTANT USE IN Ates Y, see Yilmaz AA Bremerich DH, see Rinne T
ANESTHESIOLOGY RESIDENCY see Alanoglu Z see Waibel HA
PROGRAMS IN THE UNITED STATES, S-97 Aydinli U, see Yilmazlar A Brennan MP, see Verghese ST
Ages BJ, see Rosenbaum A see Yilmazlar A Breslin DS, see Martin G
see Rosenbaum A Babin D, see Hemmerling TM see Grant SA
Aggarwal S, Nicolau RR, Planinsic R, Hilmi I, Soaita see Hemmerling TM Breukelmann D, see Dworschak M
A, Eghtesad B, HTK VERSUS UW Backus A, see Agarwala AV Nesbitt JJ, Housmans PR, TEMPERATURE
PRESERVATIVE SOLUTION: Bagchi A, Arya VK, Chari P, COMPARISON OF DEPENDENCE OF SOLUBILITY OF
HEMODYNAMIC AND METABOLIC APACHE II AND LODS (LOGISTIC ORGAN HALOTHANE, ISOFLURANE AND
CHANGES DURING ORTHOTOPIC LIVER DYSFUNCTION SYSTEM) IN AN INDIAN SEVOFLURANE, S-247
TRANSPLANTATION, S-40 MULTIDISCIPLINARY ICU, S-73 Brock J, see Joshi GP
Aguilar G, Ferrandis R, Belda F, Soro M, Garcia- Bahk J, see Park S see Ogunnaike B
Perez ML, Garcia-Raimundo M, FLOW Bailey PL, see Norton J Brock-Utne JG, HUMIDITY IN ANESTHESIA
RESISTANCE OF THE BICORE VARFLEX Baker AJ, see Hare GT BREATHING SYSTEMS, S-118
FLOW TRANSDUCER, S-145 Baker BA, see Yem JS see Chu LF
Ahmad S, see Marcus RL see Tang Y see Chandel AP
Ahmed SM, see Maroof M Banner MJ, see Praetel C Brock-Utne JJ, see Robinson MB
Ahn W, see Park S Bar-Yosef S, Mathew JP, Anderson AC, Newman MF, Brodner S, see Mersmann J
see Ryu H Landolfo KP, Grocott HP, POSTOPERATIVE Brown R, see Stapelfeldt CK
Aikins J, see Domsky R HYPERTHERMIA FOLLOWING OFF-PUMP Brunetti V, see Cook RI
Aizawa K, see Mamiya K VS. ON-PUMP CORONARY ARTERY Bryan Y, Gottlieb O, Templeton T, Coalson D,
Akhtar S, Amin M, Tantawy H, Whipple J, Barash PG, BYPASS SURGERY, S-45 DIFFERENCES IN TYMPANIC AND
Silverman DG, PREOPERATIVE BETA- Melamed R, Shakhar G, David K, Ben- RECTAL TEMPERATURE CHANGES
BLOCKADE TO A DESIRED HEART RATE Eliyahu S, THE EFFECTS OF DIFFERENT AFTER MRI OF THE BRAIN IN CHILDREN
DOES NOT NECESSARILY ACHIEVE ANESTHETIC AGENTS ON METASTATIC AFTER GENERAL ANESTHESIA, S-122
DESIRED INTRAOPERATIVE HEART RATE, DEVELOPMENT AND NATURAL-KILLER Drum M, Gottlieb O, Templeton T, Coalson
S-41 CELL ACTIVITY: A COMPARATIVE STUDY D, TO SWADDLE OR NOT: NOT ALL
Amin M, Whipple J, Tantawy H, Barash PG, IN RATS, S-248 CHILDREN BECOME HYPOTHERMIC
Silverman DG, ROUTINE USE OF Barach P, see Seiden S DURING MRI SCANNING UNDER
PREOPERATIVE BETA-BLOCKERS DOES see Vohra P GENERAL ANESTHESIA, S-224
NOT BLUNT STRESS (HEART RATE) Barash PG, see Akhtar S Buckingham M, see de Klaver MM
RESPONSE TO IMPENDING SURGERY, S- see Akhtar S Buehler E, see Girard T
260 Barker E, see Weinger MB Bullough AS, Taylor IR, Naughton N, Greenfield MV,
Akhurst T, see Veselis R Barr A, see Hare GT Wang L, PARTNER ANXIETY PRIOR TO
Alanoglu Z, Ates Y, Yilmaz AA, Tuzuner F, IS Basile F, see Fortier JD ELECTIVE CAESAREAN SECTION UNDER
THERE AN IDEAL APPROACH FOR RAPID see Fortier JD REGIONAL ANESTHESIA IN AN
SEQUENCE INDUCTION IN Basile J, see Bekker A AMERICAN TEACHING HOSPITAL, S-181
HYPERTENSIVE PATIENTS?, S-265 Beattie B, see Veselis R Bustos A, see Taboada M
Alexander L, see Sanderson IC Beckman J, see Urban MK Buvanendran A, see Kroin JS
Altintas F, see Salihoglu Z see Urban MK see Kroin JS
Amata M, see Uchida I Bekker A, Basile J, Gold M, Riles T, Kroin JS, Nagalla SK, Tuman KJ,
AMAYA o, see KLING jC DEXMEDETOMIDINE SEDATION FOR Ivankovich AD, OPIOID SENSITIVITY IN A
Amcheslavski VG, see Toma G AWAKE CAROTID ENDARTERECTOMY: RAT MODEL OF ADHESIVE LUMBAR
Amin M, see Akhtar S RATIONALE AND SAFETY, S-166 ARACHNOIDITIS, S-191
see Akhtar S Belda F, see Aguilar G Moric M, Elmofty D, Kroin JS, Tuman KJ,
Anderson AC, see Bar-Yosef S Ben-Eliyahu S, see Bar-Yosef S THE EFFECT OF ACUTE POSTOPERATIVE
Anderson KJ, Kinsella J, A SYSTEMATIC REVIEW Benedict P, see Naughton N PAIN ON RANGE OF MOTION AT TIME OF
OF THYROMENTAL DISTANCE AS A Benson KT, see Fujisawa T DISCHARGE AFTER TOTAL KNEE
PREDICTOR OF DIFFICULT see Sumita S ARTHROPLASTY, S-203
LARYNGOSCOPY, S-83 Benveniste H, see Adsumelli R Mehta A, Moric M, Tuman KJ, Lubenow
see Kinsella J Berkelmanns NG, see Herroeder S TR, THE EFFECT OF TERRORISM ON
Ang-Lee M, see Yuan C Bhatia VK, see Kumar R CHRONIC PAIN AND DEPRESSION, S-218
Ansley DM, Xia Z, Dhaliwal BS, Bilgin H, Kaya F, Köse D, Tan S, Korfali G, Kroin JS, Luk P, Rodger IW, Tuman KJ,
INTRAOPERATIVE 15-F2T-ISOPROSTANE Kutlay O, COMPARISON OF THE APPREARANCE OF ROFECOXIB, A
(8-ISO-PGF2&ALPHA; ) IS A PREDICTOR OF SUCCESS RATES USING THE SELECTIVE CYCLOOXYGENASE-2 (COX-
POST-OPERATIVE CARDIAC FUNCTION INTUBATING LARYNGEAL MASK WITH 2) INHIBITOR, IN CEREBROSPINAL FLUID
FOLLOWING WARM HEART SURGERY , S- AND WITHOUT FIBEROPTIC FOLLOWING ORAL ADMINISTRATION IN
50 GUIDANCE, S-86 PATIENTS, S-263
see Xia Z Bishop MJ, see Souders JE Byerly S, see Recart A
Xia Z, Dhaliwal BS, Wu V, INVERSE Biyani A, see Mohajer P Caballero J, see Gonzalez R
CORRELATION BETWEEN OXIDATIVE Blaine WC, see Van Den Kerkhof EG Caemaert J, see Van Aken J
STRESS AND INTERLEULIN-10/ Blum SL, see Parnass SM Cai H, see Fan Q
INTERLEULIN-6 RATIO IN PATIENTS Wu D, Schroeder A, Quarnstrom K, see Fan Q
UNDERGOING CARDIOPULMONARY Goldstein W, FASCIA ILIACA BLOCKS FOR Cakmakkaya S, see salihoglu z
BYPASS, S-52 POST-OPERATIVE ANALGESIA IN TOTAL Camara AK, see Riess ML
Aoki T, Yamaguchi H, Naito H, ORAL KNEE ARTHROPLASTY PATIENTS, S-204 Cañas A, see Gonzalez R
DEXTROMETHORPHAN PREMEDICATION Bodrogi F, see Lirk P see Gonzalez R
REDUCED POSTOPERATIVE ANALGESIC Cano E, see Gonzalez R
S-295 AUTHOR INDEX ANESTH ANALG
2003; 96; S-1–S-293
Cantillo J, see Gratz I Conner W, see Joshi GP Eells JT, see Novalija E
Cantor AB, see Vila Jr. H see Ogunnaike B Egan TD, see Manyam SC
Carls P, see Pandit JJ Cook RI, Brandwjik M, Kahana M, O'Connor M, Eghtesad B, see Aggarwal S
Carmeliet P, see Mersmann J Brunetti V, Nemeth C, BEING BUMPABLE: Egusa M, see Kohjitani A
Carr DB, see Polomano RC CONSEQUENCES OFRESOURCE Eilers H, see Schumacher MA
Cattano D, Paolicchi A, Licitra G, Panicucci E, Pelati SATURATION AND NEAR-SATURATION Ekman A, see Lennmarken C
E, Giunta F, POSTOPERATIVE COGNITIVE FOR COGNITIVE DEMANDS ON ICU El-Fandy G, EFFECT OF INCREASED INTRA-
DYSFUNCTION (POCD) AND DELIRIUM IN PRACTITIONERS, S-98 ABDOMINAL PRESSURE ON LIVER
A SHORT TIME SURVEY, S-93 Coore LA, see Feierman DE FUNCTIONS DURING LAPAROSCOPIC
Chadwick JE, see McQuillan PM Corcoran T, see Minogue SC CHOLECYSTECTOMY IN PATIENTS
Chandel AP, Van der Starre PJ, Solvason HB, Brock- Cory R, see Sanderson IC ANESTHETIZED WITH HALOTHANE
Utne JG, THE EFFECTS OF BETA- Craven R, see Fan Q VERSUS ISOFLURANE, S-125
BLOCKERS ON CEREBRAL ARTERY Crnkovich N, see Marcus RL El-Fandy G, see El-Hadidy A
BLOOD FLOW VELOCITY DURING Cross RR, see Verghese ST El-Hadidy A, BISPECTRAL INDEX
ELECTROCONVULSIVE THERAPY, S-168 Crystal GJ, see Hu G MONITORING DURING SHORT
Chari P, see Bagchi A D'Ercole F, see Martin G SURGICAL PROCEDURES USING
Chatwin DM, see Manyam SC Daley J, see Souders JE PROPOFOL ANESTHESIA, S-6
Chaudhuri K, Boone J, McGuire EL, Rivera J, Damron DS, see Shiga T El-Orbany MI, Joseph NJ, Salem M, IS THE
Chaudhuri S, DOES PREEMPTIVE Daudel F, see Westphal M POST-TETANIC COUNT/TRAIN OF FOUR
ANALGESIA REALLY WORK? A Daugherty C, see Vohra P RELATIONSHIP FOR INTENSE
COMPARISON OF OXYCONTIN, David K, see Bar-Yosef S CISATRACURIUM-INDUCED
ROFECOXIB AND PLACEBO IN PATIENTS De Baerdemaeker L, see Van Aken J NEUROMUSCULAR BLOCKADE DOSE-
UNDERGOING ELECTIVE LAPAROSCOPIC de Klaver MM, Buckingham M, Rich GF, DELAYED DEPENDANT?, S-268
CHOLECYSTECTOMY, S-200 ANESTHETIC PRECONDITIONING OF THE Elashad R, see Ghori K
Chaudhuri S, see Chaudhuri K ENDOTHELIUM AGAINST CYTOKINE- Eleff SM, see Weaver JM
Chen C, see She S INDUCEDCELL DEATH, S-15 Eletr D, see Westphal M
Chen F, Chia C, Tham C, EFFECT OF HEAD Deal E, see Gratz I Eliazo RF, see Panchal S
POSITION ON CORMACK SCALE Deal ER, Gratz I, Goldberg ME, EVALUATION OF Elliott C, see Kovac A
GRADING DURING LARYNGOSCOPY: IS BISPECTRAL INDEX (BIS) IN see Kovac A
&LSQUO;SNIFFING POSITION&RSQUO; TRAUMATIZED PATIENTS PRESENTING Elmofty D, see Buvanendran A
THE BEST?, S-156 ACUTELY TO THE OPERATING ROOM, S- Eltringham R, see Fan Q
Chen L, see Fan Q 134 Erdemli O, see Yazicioglu H
Chhokra R, see Cohen S Decou JA, see Manyam SC Ertmer C, see Westphal M
Chia C, see Chen F DeLange S, see Kroin JS Fahey, III T, see Stice-Beredino LL
Chin K, Yeo S, BISPECTRAL INDEX VALUES AT Demeyts D, see Grant SA Falabella A, see Lew MW
SEVOFLURANE CONCENTRATIONS OF 1% Demirkiran O, see salihoglu z Fam F, see Michael R
AND 1.5% IN LOWER SEGMENT see Demiroluk S Fan Q, Cai H, Liang Y, Yu B, COMPARISON OF
CESAREAN SECTION, S-175 see salihoglu z THE EFFECTS OF PROPOFOL AND
Chiu J, Tan JW, Sia AT, Yeo IS, Tan H, Demiroluk S, see salihoglu z ENFLURANE IN THE CORRECTIVE
LEVOBUPIVACAINE COMBINED WITH salihoglu z, Demirkiran O, Kose Y, THE SURGERY OF SCOLIOSIS WITH THE
FENTANYL ADMINISTERED EFFECTS OF PNEUMOPERITONEUM AND POSTERIOR INSTRUMENTATION, S-63
INTRATHECALLY FOR CESAREAN POSITION CHANGES ON INTRAOCULAR Ji M, Chen L, Cai H, Yu B, A
SECTION: A COMPARISON WITH PRESSURE, S-146 COMPARISON OF EFFECTS OF
RACEMIC BUPIVACAINE, S-185 see salihoglu z PERIOPERATIVE PULMONARY FUNCTION
Cho S, see Hara T Demiroluk SI, see Salihoglu Z IN LAPAROSCOPIC AND LAPAROTOMIC
Cho Y, see Lee C den Bakker CG, see Herroeder S CHOLECYSTECTOMY IN ELDERLY
Choiniere J, see Fortier JD Denenberg H, see Cohen S PATIENTS, S-64
see Fortier JD Dewerchin M, see Mersmann J Eltringham R, Craven R, Yu B,
Chowdary KM, Splinter WM, EFFICACY OF DeWitt DS, see Toma G COMPARISON OF THE ANAESTHETIC
SOMATIC PARAVERTEBRAL BLOCK FOR Dhaliwal BS, see Ansley DM METHODS OF MEDIUM-FLOW, LOW-
POSTOPERATIVE PAIN RELIEF IN see Ansley DM FLOW CLOSED CIRCUITS AND LOW-
CHILDREN UNDERGOING OPEN Dhar P, see Stice-Beredino LL FLOW CLOSED CIRCUITS COMBINED
APPENDECTOMY, S-226 Diemunsch P, see Meyer A WITH BISPECTRAL INDEX MONITORING
Christansen U, see Seiden S Dinkins G, see Lewis K FOR THE USE OF SEVOFLURANE, S-65
Christensen K, see Coloma M DiVittore NA, see McQuillan PM Fang Z, Keyes MA, Sabzevar F, A NOVEL
Christiansen S, see Jahn UR Diwan S, see Panchal S MIXTURE OF PROPOFOL, ALFENTANIL
Christopher BM, see Sprung J Do S, see Park S AND LIDOCAINE FOR OPHTHALMIC
Chu LF, Harrison K, Brock-Utne JG, MANUAL Dobson M, see Pandit JJ SURGERY UNDER MAC, S-12
VENTILATION OF A PATIENT TURNED Domino KB, see Souders JE Keyes MA, Sabzevar F, A NOVEL
180° AWAY FROM THE ANESTHESIA Domsky R, Goldberg ME, Rocereto T, Aikins J, MIXTURE OF PROPOFOL, ALFENTANIL
MACHINE BY A SINGLE OPERATOR, S-161 Khaleghi B, Larijani GE, ANALGESIC AND LIDOCAINE IN OBESE VS. NORMAL
Coalson D, see Bryan Y EFFECT OF A SINGLE 7.5 MG DOSE OF IV WEIGHT PATIENTS FOR SEDATION IN
see Bryan Y MORPHINE FOLLOWING TOTAL OPHTHALMIC PROCEDURES, S-258
Cohen A, see Cohen S ABDOMINAL HYSTERECTOMY: Fanning R, see Minogue SC
see Cohen S COMPARISON TO PLACEBO, S-207 Feierman DE, Coore LA, Silverstein J, THE
Cohen IT, THE LEARNING STYLES OF Donahue BS, Gailani D, George, Jr AL, FACTOR V EFFECTS OF ACETAMINOPHEN ON THE
ANESTHESIOLOGISTS, S-96 LEIDEN PROTECTS AGAINST BLOOD PHARMACOKINETICS OFORAL
Cohen S, Denenberg H, Mohiuddin R, Uzun N, LOSS AND TRANSFUSION FOLLOWING MIDAZOLAM, S-262
Chhokra R, Cohen A, IS EPIDURAL-PCA CARDIAC SURGERY, S-58 Felleiter P, see Lierz P
ANALGESIA NECESSARY FOR A THIRD Donati F, see Hemmerling TM Ferrandis R, see Aguilar G
DAY POST CESAREAN SECTION PAIN?, S- see Hemmerling TM Feshchenko V, see Veselis R
179 Dorian R, see Rafizadeh M Fields AM, see Richards TA
Mohiuddin R, Prasad A, Uzun N, Driessen B, see Jahr JS see Richards TA
Soremeken O, Cohen A, DOES SUTURING Drum M, see Bryan Y Richards TA, Ibrahim IN, Kaye AD, THE
IMPROVE THE RATE OF SUCCESSFUL Durieux ME, see Herroeder S EFFECTS OF NOREPINEPHRINE IN THE
REACTIVATION OF LABOR EPIDURAL see Herroeder S PULMONARY VASCULAR BED OF THE
CATHETERS FOR POSTPARTUM TUBAL Dworschak M, Breukelmann D, Hannon JD, IMPACT CAT, S-230
LIGATION (PPTL) SURGERY?, S-183 OF ISOFLURANE DURING SIMULATED Richards TA, Ibrahim IN, Kaye AD, MA
Coloma M, Recart A, White PF, Griffin JD, MYOCARDIAL ISCHEMIA/REPERFUSION HUANG VASOPRESSOR EFFECTS ARE
Gottschalk F, Christensen K, EFFECT OF ON INTRACELLULAR CALCIUM, MEDIATED BY AN ALPHA1B RECEPTOR IN
LOCAL ANESTHETIC WOUND ARRHYTHMIA AND CONTRACTILITY, S- THE PULMONARY VASCULAR BED OF
ADMINISTRATION ON RECOVERY AFTER 17 THE CAT, S-231
MAJOR ORTHOPEDIC SURGERY Eberhart LH, see Kranke P Figallo CM, see Williams BA
PROCEDURES, S-205 Edsberg L, see Hahn RG
2003; 96; S-1–S-293
Finegold H, Ohara C, Ramananathan S, Goldberg M, see Khaleghi B NICOTINIC RECEPTORS-MEDIATED

ENOXAPARIN THERAPY DURING see Gratz I EFFECTS OF TAAC3, A NEW ULTRASHORT
PREGNANCY AND MANAGEMENT OF Goldberg ME, see Deal ER ACTING MUSCLE RELAXANT IN THE RAT,
LABOR ANALGESIA, S-178 see Domsky R S-237
Fisher JA, see Ito S Goldstein DH, see Van Den Kerkhof EG Hagberg CA, Iannucci DG, Goodrich AL, AN
Flatto RM, see McQuillan PM Goldstein W, see Blum SL EVALUATION OF ENDOTRACHEAL
Fortier JD, Choiniere J, Basile F, Prieto I, Gomez I, see Gonzalez R INTUBATION USING THE MACINTOSH
Hemmerling T, ULTRA-FAST-TRACK Gonzalez R, Garcia F, Serrano C, Cañas A, VIDEO LARYNGOSCOPE, S-157
ANESTHESIA IN OFF-PUMP CARDIAC PROSPECTIVE EXAMINATION OF Hahn RG, Waldrop KS, Edsberg L, Svensén CH,
SURGERY: POSTOPERATIVE EPIDURAL EPIDURAL CATHETER INSERTION, S-182 NATRIURESIS GOVERNS THE DURATION
ANALGESIA VERSUS PCA MORPHINE, S- Cano E, Caballero J, Garcia F, OF THE EXTRACELLULAR VOLUME
47 PAMIDRONATE PRODUCES PAIN RELIEF EXPANSION AFTER INFUSION OF
Choiniere J, Basile F, Prieto I, Hemmerling FOR CHRONIC BACK PAIN IN HYPERTONIC SALINE IN SHEEP, S-242
TM, OPERATING ROOM EXTUBATION IN GLUCOCORTICOID-INDUCED Hall BA, see Rinne T
SIMPLE AND COMPLICATED AORTIC OSTEOPOROSIS, S-214 see Waibel HA
VALVE SURGERY: A FIRST EXPERIENCE, Serrano C, Gomez I, Valdivieso E, Hames K, see Pandit JJ
S-48 PERIBULBAR BLOCK FOR CATARACT see Pandit JJ
Francis KA, see Williams BA SURGERY, S-281 Hammel D, see Jahn UR
Fu ES, see Soto RG Serrano C, Cañas A, Prieto J, INFLUENCE Hamza MA, Recart A, White P, Schneider B,
Fuchigami T, see Nakamura S OF THE PATIENTS POSITION DURING Ogunnaike B, ROLE OF HEATED AND
Fujisawa T, Sumita S, Benson KT, Kindscher JD, INDUCTION OF COMBINED SPINAL- HUMIDIFIED INTRAPERITONEAL GASES
Goto H, THE EFFECT OF GP683, A NOVEL EPIDURAL ANESTHESIA FOR TOTAL DURING LAPAROSCOPIC ROUX-EN-Y
ADENOSINE KINASE INHIBITOR, ON KNEE ARTROPLASTY, S-289 SURGERY - EFFECT ON CORE
HEMODYNAMIC AND SYMPATHETIC Goodrich AL, see Hagberg CA TEMPERATURE AND POSTOPERATIVE
OUTFLOW IN NERVE-INTACT AND Gordin V, see Polomano RC PAIN
BARORECEPTOR-DENERVATED RABBITS, Goto F, see Yoshikawa D , S-121
S-24 see Kawahara F Han S, see Yang H
see Sumita S Goto H, see Fujisawa T Hanaoka K, see Nishiyama T
Fujiwara Y, see Okamura H see Sumita S see Nishiyama T
Fukusaki M, Miyako M, Sumikawa K, A DOSE- Gottlieb O, see Bryan Y Hanazaki M, see Yokoyama M
RESPONSE STUDY OF PROSTAGLANDIN see Bryan Y Hankins D, see McGlinch BP
E1 ON RADICULAR BLOOD FLOW Gottschalk F, see Coloma M Hannallah RS, see Verghese ST
VELOCITY AFTER LUMBAR Govindan K, see Michael R see Verghese ST
DISCECTOMY, S-39 Gramlich L, Kroin JS, Tubic G, McCarthy RJ, Tuman see Verghese ST
see Takada M KJ, APROTININ PHARMACOKINETICS Hannon JD, see Dworschak M
Gabrielli A, see Praetel C DURING CARDIOPULMONARY BYPASS IN Hara T, Oshibuchi M, Yoshitomi O, Cho S, Tomiyasu
Gailani D, see Donahue BS SMALL PEDIATRIC PATIENTS, S-53 S, Sumikawa K, FENTANYL PROTECTS
Gambhir S, see Kinsella J Grant SA, see Martin G STUNNED MYOCARDIUM IN DOGS, S-20
Gandert H, see Kopf A Demeyts D, Breslin DS, Macleod DB, Hardman D, see Grant SA
Garcia F, see Gonzalez R Martin G, Hardman D, EXPERIENCE Hare GT, Mazer C, Mak W, Hum KM, Barr A, Baker
see Gonzalez R REDUCES VARIABILITY IN AJ, HEMODILUTIONAL ANEMIA CAUSES
Garcia-Perez ML, see Aguilar G DETERMINATION OF POINT OF NEEDLE TRANSIENT CEREBRAL HYPOXIA AND
Garcia-Raimundo M, see Aguilar G INSERTION IN PERIPHERAL NERVE INCREASED CORTICAL NNOS MRNA
Gasanova I, see Recart A BLOCKS, S-282 LEVELS, S-26
Recart A, White PF, Thomas T, Oggunaike Grattan A, Smith A, Kelly T, Shaw A, Royston D, Harmon DC, see Ghori K
B, DOES CEREBRAL MONITORING Riedel BJ, MEDIUM-TERM OUTCOME see Ghori K
FACILITATES RECOVERY AFTER FOLLOWING CORONARY Harner CD, see Williams BA
GENERAL ANESTHESIA? A COMPARISON REVASCULARIZATION: CPB VERSUS OP- Harrison K, see Chu LF
OF AEP AND BIS MONITORING CAB, S-46 Harvey HA, see Polomano RC
, S-129 Gratz I, see Deal ER Havidich JE, Haynes G, Lineberger CK, Reves JG,
Ge JJ, see Lew MW see Khaleghi B THE EFFECT OF THE ADDITIONAL (PGY-
Gelnett CM, see McQuillan PM Cantillo J, Deal E, Goldberg M, Khaleghi B, 4) YEAR ON SUBSPECIALTY EDUCATION:
see McQuillan PM Larijani GE, CARDIOVASCULAR AND A TEN YEAR REVIEW, S-94
George, Jr AL, see Donahue BS RESPIRATORY EFFECTS OF A SINGLE 7.5 Haynes G, see Havidich JE
Ghori K, Harmon DC, Ullrich K, Wei L, Walsh F, MG DOSE OF IV MORPHINE COMPARED Heinatz A, see Lierz P
Shorten GD, EFFECT OF MIDAZOLAM ON TO PLACEBO IN POSTOPERATIVE Heinbuch G, see Knuepfer PE
EXPRESSION OF NEUTROPHIL ADHESION PATIENTS, S-209 Heisner JS, see Novalija E
MOLECULES CD11B & CD18 IN VITRO, S- Greenfield J, see Schultz JR Helgeson L, see Taboada M
69 Greenfield MV, Rosenberg AL, Nauss MD, Shanks A, Hemmerling T, see Fortier JD
Elashad R, Harmon DC, Walsh F, O'Sullivan Sliwinski M, O'Reilly M, QUALITY OF Hemmerling TM, see Fortier JD
MG, Shorten GD, ASSOCIATION BETWEEN STUDY PROTOCOLS AND DATA Trager G, Babin D, Donati F, Mathieu P, A
PLASMA CONCENTRATION OF NITRIC ANALYSES IN RANDOMIZED PROTOTYPE NEUROMUSCULAR
OXIDE PRODUCT (NITRATE & NITRITE) CONTROLLED TRIALS AMONG GENERAL MONITOR USING PHONOMYOGRAPHY, S-
AND S100B PROTEIN AFTER SURGERY OF ANESTHESIOLOGY JOURNALS, S-88 136
CEREBRAL ANEURSYM CLIPPING AND see Naughton N Babin D, Donati F, OFFSET OF
PATIENT OUTCOME, S-169 see Bullough AS NEUROMUSCULAR BLOCK IS LONGER AT
Giffard RG, Ouyang Y, EARLY MITOCHONDRIAL see Turner CR THE ABDUCTING LARYNGEAL MUSCLE
CHANGES IN RESPONSE TO ISCHEMIA- Gregory T, see Marcus RL THAN AT THE ADDUCTING LARYNGEAL
LIKE INJURY - EFFECTS OF BCL-XL, S-174 Griffin JD, see Coloma M MUSCLES IN HUMANS, S-269
Gilbert W, see Sanderson IC Grocott HP, see Yang H Hemmings HC, see Panchal S
Giles J, see Sear JW see Bar-Yosef S Henderson WG, see Souders JE
Ginz H, see Girard T see Homi HM Henri M, see Meyer A
Girard T, Ginz H, Voronkov E, Buehler E, Urwyler A, Grosse Bockhorn S, see Menzebach A Henry MM, see Novalija E
CHOLINESTERASE DEFICENCY: Gu J, see Xia Z Herman K, see Jahr JS
IDENTIFICATION OF A NOVEL Gunther RA, see Jahr JS Herr DL, see Jorden V
MUTATION, S-241 Gust AM, Small RH, LEFT ATRIUM COMPUTER Herroeder S, den Bakker CG, Marcus MA, Martin E,
Girgenti GT, see Sprung J MODEL THAT ACCURATELY SIMULATES Durieux ME, Hollmann MW, SITE OF
Giunta F, see Cattano D PRESSURE, FLOW, AND ACTION OF TIME-DEPENDENT
Giurgiuman LM, see ISETTA CJ VOLUME,INCLUDING MASS EFFECT AND INHIBITION BY LOCAL ANESTHETICS, S-
Glass P, see Adsumelli R STARLING'S LAW, S-30 249
Gleason DH, see Martin G Gustorff B, see Lierz P Berkelmanns NG, Struemper D, Martin E,
Glisson S, see Marcus RL Gyermek L, see Lee C Durieux ME, Hollmann MW, MECHANISMS
Gohara T, see Ishida K Lee C, Nguyen N, Nguyen N, Nguyen N, OF TIME-DEPENDENT INHIBITION BY
Gold M, see Bekker A PERIPHERAL MUSCARINIC AND LOCAL ANESTHETICS, S-250
2003; 96; S-1–S-293
Higuchi H, see Kohjitani A Jahn UR, Christiansen S, Van Aken H , Scheld HH, Kevin LG, Katz P, Riess ML, Novalija E, Stowe DF,
Hilmi I, see Aggarwal S Hammel D, Kehrel BE, CIRCULATING ANESTHETIC PRECONDITIONING:
Hilmi IA, Abdullah R, Nicolau-Raducu R, Soaita A, PLATELET-LEUKOCYTE ASSOCIATES IN EFFECTS ON LATENCY TO ISCHEMIC
Sullivan E, Quinlan J, THE INCIDENCE & PATIENTS ON THE NOVACOR AND INJURY IN ISOLATED HEARTS, S-14
ETIOLOGY OF REINTUBATION DURING HEARTMATE VENTRICULAR ASSIST see Novalija E
THE FIRST 24 HOURS FOLLOWING DEVICE, S-36 see Riess ML
SURGERY AND ANESTHESIA: A TWO Jahr JS, see Johnson C Keyes MA, see Fang Z
YEAR RETROSPECTIVE ANALYSIS, S-87 Li QL, Rothenberg SJ, Driessen B, Gunther see Fang Z
Hirsh R, see Khaleghi B RA, ACCURACY OF LACTATE Khaleghi B, see Domsky R
Hiruta H, see Nakatani T MEASUREMENT IN BOVINE BLOOD Goldberg M, Warshal D, Hirsh R, Gratz I,
Hoffman W, see Paisansathan C SAMPLES CONTAINING VARYING Larijani GE, ANALGESIC EFFECT OF A
Hoffman WE, Paisansathan C, Weinberg G, THE CONCENTRATIONS OF HEMOGLOBIN- SINGLE 7.5 MG DOSE OF IV MORPHINE
EFFECT OF BUPIVACAINE ON BASED OXYGEN CARRIER (HBOC): A FOR THE TREATMENT OF PAIN AFTER
MYOCARDIAL TISSUE HYPOXIA AND TEST OF TWO LACTATE ANALYZERS, S- RADICAL PROSTATECTOMY:
ACIDOSIS DURING VENTRICULAR 76 COMPARISON TO PLACEBO, S-208
FIBRILLATION, S-21 Nesargi S, Herman K, Tang Z, Rothenberg see Gratz I
Hoka S, see Kimotsuki H SJ, LEAD EFFECTS: OXYGEN Khan RM, see Maroof M
Hollmann MW, see Herroeder S HEMOGLOBIN DISSOCIATION IN BOVINE Khuri S, see Souders JE
see Herroeder S BLOOD USING OXYGEN CONTENT FROM Kim D, see Ryu H
MECHANISMS AND SITE OF ACTION TONOMETRY AND A LEXO2CON OXYGEN Kim J, see Yang H
FOR TIME-DEPENDENT INHIBITION BY ANALYZER, S-77 Kimotsuki H, Okamoto H, Hoka S, DUAL EFFECTS
LOCAL ANESTHETICS, S-254 see Lewis K OF DEXMEDETOMIDINE ON REACTIVE
Hollowell L, see Sanderson IC Ji M, see Fan Q HYPEREMIA AND INFARCT SIZE
Homi HM, see Yang H Johnson C, Sapien RL, Rothenberg SJ, Miceli R, Jahr FOLLOWING FOCAL CEREBRAL
Yokoo N, Ma D, Warner DS, Maze M, JS, TRAUMA DEMOGRAPHICS FOR LA ISCHEMIA IN RATS, S-165
Grocott HP, THE NEUROPROTECTIVE COUNTY AND PRIVATE HOSPITALS: Kindscher JD, see Fujisawa T
EFFECT OF XENON ADMINISTRATION TRENDS IN TRAUMA ADMISSIONS, S-72 King T, see Urban MK
DURING TRANSIENT MIDDLE CEREBRAL Johnson KB, see Manyam SC Kinsella J, see Anderson KJ
ARTERY OCCLUSION IN MICE, S-167 Jones S, see Recart A Gambhir S, Anderson KJ, POPULATION
Horowitz PE, Thomas J, Soto RG, DELIVERY OF Jorden V, Herr DL, CHARACTERIZATION AND THYROMENTAL DISTANCE CHANGES
NORMOTHERMIC BLOOD AND FLUIDS MANAGEMENT DEXMEDETOMIDINE- WITH ETHNICITY, S-84
TO PEDIATRIC PATIENTS USING A DRY RELATED HYPOTENSION FOLLOWING Kirby D, see Urdaneta F
HEAT WARMER, S-153 CABG, S-255 Kitagawa T, see Okamura H
Hou W, see Xia Z Joseph NJ, see Megally M Kitano T, Nisimaru N, Kawabe S, Nakamura T,
Houchin K, see Paulsen A see El-Orbany MI Iwasaka H, Noguchi T, EFFECTS OF
Housmans PR, see Breukelmann D Joshi GP, Ogunnaike B, Conner W, Brock J, INTRACELLULAR ACIDOSIS ON THE
Hsu ES, INTERVENTIONAL PAIN BISPECTRAL INDEX MONITORING IN STEADY STATE RATES OF CREATINE
MANAGEMENT ON POSTPOLIO MECHANICALLY VENTILATED KINASE IN RAT BRAIN SLICES, S-171
SYNDROME(PPS), S-217 CRITICALLY ILL PATIENTS, S-66 Kivlahan C, see Seiden S
Hu G, Salem M, Crystal GJ, PRETREATMENT see Ogunnaike B Klein K, see Recart A
WITH VOLATILE ANESTHETICS Jules-Elysee K, see Urban MK Klimaschewski L, see Lirk P
PREVENTS NEUTROPHIL-INDUCED Kadoi Y, see Yoshikawa D Kling Jc, Amaya O, Montes Fr, Pino S,
CONTRACTILE DYSFUNCTION IN see Kawahara F ENDOTRACHEAL LIDOCAINE WITH
ISOLATED RAT HEARTS: LACK OF ROLE Kahana M, see Cook RI DISPERSION STEAM FOR AWAKE
FOR KATP CHANNELS, S-32 Kakinohana M, see Nakamura S EXTUBATION, S-162
Hum KM, see Hare GT Kanaide M, see Takada M Klösel S, see Rinne T
Iannucci DG, see Hagberg CA Kanata K, see Nakatani T Knuepfer PE, Heinbuch G, MODERN
Ibrahim IN, see Richards TA Karabayirli S, see Yilmaz AA ANAESTHETIC AGENTS FOR GENERAL
see Richards TA Karan S, see Norton J ANAESTHESIA IN THIRD WORLD
see Fields AM Kariya N, Nishi S, Asada A, Mazoit J, COUNTRIES, S-114
see Fields AM VENTRICULAR FIBRILLATION IS LIKELY Kobayashi N, see Uchida I
Igarashi T, see Nagata O TO APPEAR AT THE MOMENT ON THE Kobayashi Y, see Ishikawa A
Ilgaz O, see Yilmazlar A DECLINE OF THE BUPIVACAINE Kodaka M, Uchida J, Maeyama A, Ishizuka I, Miyao
see Yilmazlar A CONCENTRATION IN RABBITS - H, SEVOFLURANE MAC AND CP50 FOR
Isetta CJ, Giurgiuman LM, MALZAC B, EARLY COMPARATIVE PHARMACODYNAMIC INSERTION OF PROSEAL VS CLASSIC
EXTUBATION IN 100 CONSECUTIVE STUDY OF THE CARDIOTOXITY LARYNGEAL MASK, S-267
PATIENTS AFTER CARDIAC SURGERY BETWEEN THE RACEMIC AND LEVO Kohjitani A, Miyawaki T, Egusa M, Higuchi H,
WITH CARDIOPULMONARY BYPASS, S-49 BUPIVACAINES, S-253 Shimada M, OROPHARYNGEAL WATER
Ishida K, Ohtake K, Gohara T, Morimoto Y, Katayama H, see Oku S ACCUMULATION INCREASES
Matsumoto M, Sakabe T, DISSOCIATION Katsuya H, see Ito S SUSCEPTIBILITY TO CHOKING DURING
BETWEEN REGIONAL CEREBRAL AND Katz P, see Kevin LG DENTAL TREATMENT OF INTELLECTUAL
JUGULAR VENOUS OXYGEN Kawabe S, see Kitano T DISABILITY UNDER DEEP SEDATION, S-7
SATURATION IN CARDIOVASCULAR Kawahara F, see Yoshikawa D Kondabolu S, see Adsumelli R
SURGERY WITH HYPOTHERMIC Kadoi Y, Saito S, Goto F, SLOW Kopacz DJ, see Smith KN
CARDIOPULMONARY BYPASS, S-60 REWARMING IMPROVES JUGULAR Kopf A, Aden U, Gandert H, Luck T, Stein C,
Ishikawa A, Kobayashi Y, Aoyama Y, PAIN VENOUS OXYGEN SATURATION DURING PATIENTCONTROLLED INTRAVENUOUS
MANAGEMENT FOR A PREGNANT REWARMING PERIOD, S-61 ANALGESIA: MORPHINE VERSUS
PATIENT WITH UTERUS LEIOMYOMA - A Kawasaki J, Tanaka KA, Takei H, Maruo T, Miyao H, PIRITRAMIDE, S-202
LONG-TERM EPIDURAL INFUSION OF ELECTRONMICROSCOPIC EVALUATION Korfali G, see Bilgin H
ROPIVACAINE, S-210 OF CLOT FORMATION ON Korkmaz T, see Yilmaz AA
Ishizuka I, see Kodaka M THROMBOELASTOGRAM, S-155 Kornblatt I, see Parnass SM
Issioui T, see Recart A Kawase K, see Okamura H Köse D, see Bilgin H
Itano Y, see Yokoyama M Kaya F, see Bilgin H Kose Y, see salihoglu z
Ito S, Sasano H, Sasano N, Tomita Y, Katsuya H, Kaya G, see salihoglu z see Demiroluk S
Fisher JA, VAGAL NERVE BLOCKADE Kaye AD, see Richards TA see salihoglu z
INCREASES DEAD SPACE VENTILATION see Richards TA Kotake Y, see Takagi EN
IN HUMAN, S-144 see Fields AM Kovac A, Jacobs K, Weber C, Elliott C,
Ivankovich AD, see Kroin JS see Fields AM VARIABILITY OF EXCLUSION CRITERIA
see Buvanendran A Kehrel BE, see Jahn UR USED IN MUSCLE RELAXANT
Iwakiri H, see Nagata O Kelly T, see Grattan A RANDOMIZED CONTROLLED TRIALS, S-
Iwasaka H, see Kitano T Kelsey W, see Urban MK 89
Iwasaki H, see Mamiya K see Urban MK Picillo K, Elliott C, COMPARISON OF
Jacobs K, see Kovac A Kentor ML, see Williams BA ANALGESIC, ANTIEMETIC AND ANTI-
Jaffar M, see Munir MA HYPERTENSIVE MEDICATIONS IN THE
2003; 96; S-1–S-293
POSTANESTHESIA CARE UNIT PROSTATECTOMY USING Mannes AJ, see Polomano RC

FOLLOWING USE OF REMIFENTANIL FOR INTRAOPERATIVE SPIROMETRY, S-92 Manyam SC, Chatwin DM, Decou JA, Johnson KB,
MONITORED ANESTHESIA CARE VERSUS Lewis A, Osborn I, Roth R, THE EFFECT OF White JL, Egan TD, THE AUDITORY
GENERAL ANESTHESIA, S-273 LISTENING TO HEMISPHERIC EVOKED POTENTIAL AND THE
Kracke GR, see Landrum AL SYNCHRONIZATION ON THE AMOUNT OF BISPECTRAL INDEX: A COMPARISON
Kranke P, Eberhart LH, Apfel CC, Morin AM, INTRAOPERATIVE ANALGESIA STUDY EXAMINING SIGNAL RESPONSES
Roewer N, EFFICACY AND SAFETY OF REQUIRED, S-257 TO INADEQUATE ANESTHESIA, S-132
TROPISETRON FOR THE PREVENTION OF Lewis K, Dinkins G, McQuirter J, Rothenberg SJ, Marcet JE, see Miguel RV
POSTOPERATIVE NAUSEA AND Manalo M, Jahr JS, DO VARYING LEAD Marcus MA, see Herroeder S
VOMITING: A QUANTITATIVE LEVELS INTERFERE WITH Marcus RL, Ahmad S, Crnkovich N, Glisson S,
SYSTEMATIC REVIEW (METAANALYSIS), COAGULATION: AN IN VITRO Gregory T, NONINVASIVE CARDIAC
S-1 THROBELASTOGRAPHY (TEG) STUDY OUTPUT MONITORING FACILITATES
Kroin JS, see Gramlich L WITH WHOLE BLOOD, S-154 INTRAOPERATIVE FLUID MANAGEMENT
Buvanendran A, Nagalla SK, Tuman KJ, Li QL, see Jahr JS FOR MAJOR GYNECOLOGIC ONCOLOGY
Ivankovich AD, ANALGESIC DRUG Liang Y, see Fan Q PROCEDURES, S-139
SENSITIVITY IN A NEW RAT MODEL OF Lichtenthal PR, Borg UR, TRUCCOMS--AN Marfin AG, see Pandit JJ
POST-THORACOTOMY PAIN, S-189 ACCURATE SYSTEM FOR CARDIAC see Pandit JJ
Ling ZD, Buvanendran A, DeLange S, OUTPUT MEASUREMENT?, S-140 Maroof M, Ahmed SM, Khan RM, Singhal V, Rizvi
Tuman KJ, INFLUENCE OF POST- Licitra G, see Cattano D KA, A COMPARISON OF LARYNGEAL
OPERATIVE PAIN ON SPINAL Lierz P, Heinatz A, Gustorff B, Felleiter P, MASK AIRWAY AND PA XPRESS, S-85
CYCLOOXYGENASE-2 (COX-2) IN RATS, CONTINUOUS APPLICATION OF Martin E, see Herroeder S
S-190 INTRATHECAL MORPHINE IN PHANTOM see Herroeder S
see Buvanendran A PAIN, S-216 Martin G, Breslin DS, D'Ercole F, Grant SA, MacLeod
see Buvanendran A Lineberger CK, see Havidich JE DB, Gleason DH, CORRELATION BETWEEN
see Buvanendran A Ling ZD, see Kroin JS STROKE VOLUME AND LEFT
see Mohajer P Lirk P, Summer G, Bodrogi F, Rieder J, VENTRICULAR EJECTION TIME IN THE
Krombach J, Perretta S, Pelligrini F, Lobo E, Patti M, Schobersberger W, OCCUPATIONAL PRONE POSITION USING
Niemann CU, EVOLUTION OF ANESTHESIA EXPOSURE TO SEVOFLURANE: TRANSESOPHAGEAL ECHO-DOPPLER
MANAGEMENT FOR BARIATRIC ASSESSMENT IN EXHALED BREATH, S- MONITORING, S-137
SURGERY, S-91 148 see Grant SA
Kumar R, Sethi M, Sehgal R, Bhatia VK, A Klimaschewski L, Longato S, Rieder J, Martin GR, see Verghese ST
PROSPECTIVE, RANDOMIZED, CISATRACURIUM, BUT NOT Maruo T, see Kawasaki J
CROSSOVER STUDY TO ASSESS THE MIVACURIUM, DECREASES SURVIVAL OF Mashimo T, see Ueta K
ENDOTRACHEAL TUBE CUFF INFLATION RAT SYMPATHETIC NEURONS IN VITRO, Mathew JP, see Bar-Yosef S
AS A MEANS OF IMPROVING SUCCESS S-239 Mathieu P, see Hemmerling TM
RATE OF BLIND NASOTRACHEAL Liu C, see She S Matsumoto M, see Ishida K
INTUBATION (BNI) UNDER VARIOUS Lobato E, see Urdaneta F May JH, see Strum DP
CONDITIONS, S-158 Lobo E, see Krombach J see Strum DP
Kuruefe R, see Yilmazlar A see Stapelfeldt CK Maze M, see Homi HM
see Yilmazlar A Locher S, see Megally M Mazer C, see Hare GT
Kurup VJ, Taboada M, Atanassoff P, EFFECT OF Longato S, see Lirk P Mazoit J, see Kariya N
SPINAL ANESTHESIA ON PROCESSED Lox M, see Mersmann J McCarthy RJ, see Gramlich L
EEG, S-284 see Menzebach A McDonald SB, see Smith KN
Kushizaki H, see Nakatani T Lu Y, Laurito C, Pappas G, Votta-Valis G, Yeomans D, McGlinch BP, White RD, Hankins D, THE USE OF
Kussman BD, Madril DR, Walsh EP, Laussen PC, DEVELOPMENT OF A PRIMATE PREHOSPITAL RAPID SEQUENCE
ANESTHETIC IMPLICATIONS OF BEHAVIORAL NOCICEPTIVE ASSAY, S-188 INTUBATION BY PARAMEDICS FOR
EPICARDIAL PACEMAKER PLACEMENT Lu Z, Wang Y, Yu B, THE EFFECT OF DOSAGE AIRWAY MANAGEMENT IN MEDICAL
IN NEONATES WITH CONGENITAL AND TIMING OF NEOSTIGMINE EMERGENCIES, S-79
COMPLETE HEART BLOCK, S-222 ADMINISTRATION ON REVERSAL OF McGuire EL, see Chaudhuri K
Kutlay O, see Bilgin H VECURONIUM-INDUCED McKinney GL, see Landrum AL
see Yilmazlar A NEUROMUSCULAR BLOKADE INA McQuay H, see Pandit JJ
see Yilmazlar A REPITITIVE DOSE (VECURONIUM) MODE, McQuillan PM, Gelnett CM, Schuler H, DiVittore
see Yilmazlar A S-271 NA, Polomano RC, Orkin FK, EVALUATION
Lagasse RS, see Ramachandran S Lubenow TJ, see Mohajer P OF AN OBSERVATIONAL DATABASE FOR
Lalmansingh A, see Veselis R Lubenow TR, see Buvanendran A OUTCOMES WITH EPIDURAL ANALGESIA
Landolfo KP, see Bar-Yosef S Luck T, see Kopf A IN PEDIATRIC POST-SURGICAL PATIENTS,
Landrum AL, McKinney GL, Tilghman BM, Kracke Luk P, see Buvanendran A S-225
GR, DIFFERENTIAL INHIBITION OF Ma D, see Homi HM Gelnett CM, Polomano RC, Chadwick JE,
CYCLIC NUCLEOTIDE-GATED CHANNELS Ma H, Tang J, White PF, Wender RH, Zaentz A, Flatto RM, Orkin FK, AN ANALYSIS OF
BY LOCAL ANESTHETICS, S-251 ROFECOXIB PREMEDICATION IMPROVES CLINICAL OUTCOMES WITH EPIDURAL
Larijani GE, see Domsky R OUTCOME AFTER OUTPATIENT ANALGESIA IN ADULT POST-SURGICAL
see Khaleghi B INGUINAL HERNIORRHAPHY, S-2 PATIENTS, S-292
see Gratz I see Tang J McQuirter J, see Lewis K
Larmann J, see Mersmann J Macaluso A, see Recart A Megally M, Joseph NJ, Xie X, Salem M, Locher S,
see Menzebach A Mackey DC, see Vila Jr. H DOES RESPONSE TME TO
Laurito C, see Lu Y MacLeod DB, see Martin G INITIATEEPIDURAL ANALGESIA FOR
Laussen PC, see Kussman BD Macleod DB, see Grant SA LABOR AFFECT PATIENT SATISFACTION?,
LeDez k, see Bolis RS Madorsky SV, see Toma G S-180
Lee C, Gyermek L, Nguyen NB, Cho Y, Tsai S, Madril DR, see Kussman BD Mehendale S, see Yuan C
NEUROMUSCULAR BLOCK BY INFUSION Maekawa T, see Nakamura T Mehta A, see Buvanendran A
OF TAAC3 IN THE PRIMATE, S-236 Maeyama A, see Kodaka M Melamed R, see Bar-Yosef S
see Gyermek L Maja V, see Viertiö-Oja H Menzebach A, Lox M, Weitkamp B, Larmann J,
Lee K, see Park S Mak W, see Hare GT Mersmann J, Grosse Bockhorn S, Van Aken H,
Lee Y, see Yang H Makita T, see Yoshimura M Singbartl K, Theilmeier G, A MURINE
Lehning EJ, see Ramachandran S see Nakamura T MODEL FOR POST-ISCHEMIC
see Ramachandran S see Shibata O INFLAMMATORY ORGAN DAMAGE AND
Lele A, see Rafizadeh M Maleckar S, see Yuan C FUNCTIONAL RECOVERY AFTER
Lemmens HJ, see Robinson MB Malzac B, see Isetta CJ CARDIOPULMONARY RESUSCITATION
Lennmarken C, Ekman A, Sandin R, INCIDENCE OF Mamiya K, Sekikawa T, Aizawa K, Sengoku K, (CPR), S-70
AWARENESS USING BIS-MONITORING, S- Takahata O, Iwasaki H, AXILLARY BLOCK Mersmann J, Larmann J, Lox M, Brodner S, Van
133 WITH NEWLY DEVELOPED PENTAGON Aken H, Dewerchin M, Carmeliet P, Theilmeier
Lew MW, Falabella A, Ge JJ, THE PULMONARY POINTED NEEDLE, S-199 G, REDUCED LEUKOCYTE RECRUITMENT
CHANGES IN LAPAROSCOPIC RADICAL Manalo M, see Lewis K IN MICE DEFICIENT FOR THE
Maniwa Y, see Uchida I UROKINASE RECEPTOR (U-PAR) IS
2003; 96; S-1–S-293
ASSOCIATED WITH SMALLER INFARCTS INHIBITORS IN REDUCING NON- AND HYPOXIA ON UPPER AIRWAY
AND IMPROVED REGIONAL FUNCTION INCISIONAL POST-THORACOTOMY PAIN, OBSTRUCTION, S-275
AFTER TRANSIENT MYOCARDIAL S-196 Novalija E, see Kevin LG
ISCHEMIA, S-19 Munkel H, see Singbartl G Kevin LG, Heisner JS, Henry MM, Eells JT,
see Menzebach A see Singbartl G Stowe DF, ANESTHETIC
Meyer A, Schaeffer C, Raiga J, Schaeffer R, Henri M, see Singbartl G PRECONDITIONING TRIGGERED BY ROS
Diemunsch P, GAS COMPOSITION OF see Singbartl G IMPROVES MITOCHONDRIAL ATP
PNEUMOPERITONEUM DURING Murray PA, see Shiga T SYNTHESIS AND DECREASES ROS
LAPAROSCOPIC GYNECOLOGIC Nagalla SK, see Kroin JS FORMATION AFTER ISCHEMIA IN
PROCEDURES, S-142 see Buvanendran A GUINEA PIG HEARTS, S-16
Miceli R, see Johnson C Nagata O, Igarashi T, Iwakiri H, Ozaki M, O'Connor M, see Cook RI
Michael R, Younan N, Fam F, Abadir AR, CLINICAL PHARMACOKINETIC SIMULATION O'Reilly M, see Greenfield MV
AND EXPERIMENTAL EVALUATION OF EXPLAINS THE MEASURED PROPOFOL see Naughton N
THE MUSCLE RELAXANT EFFECT OF CONCENTRATION RISING HIGHER THAN O'Sullivan MG, see Ghori K
NEFOPAM HCL(A NON-NARCOTIC THE PREDICTED VALUE, S-126 Oggunaike B, see Gasanova I
ANALGESIC), S-193 Naito H, see Aoki T Ogunnaike B, see Joshi GP
Sabry MM, Govindan K, Abadir AR, ROLE Nakamura S, Kakinohana M, Fuchigami T, Sugahara Joshi GP, Conner W, Brock J, SEDATION
OF NALOXONE AND AUTOLOGOUS K, LOW DOSE BUPRENORPHINE IN MECHANICALLY VENTILATED
BLOOD TRANSFUSION ON THE ENHANCE THE SPASTIC PARAPARESIS CRITICALLY ILL PATIENTS: USE OF
RECOVERY FROM HEMORRHAGIC INDUCED BY INTRATHECAL MORPHINE BISPECTRAL INDEX MONITORING, S-67
SHOCK IN DOGS, S-243 AFTER NON- INJURIOUS INTERVAL OF see Hamza MA
Michelotti G, Smith MP, Schwinn DA, CLONING SPINAL ISCHEMIA IN RATS, S-234 Oguri K, see Okamura H
AND CHARACTERIZATION OF THE RAT Nakamura T, see Kitano T Ohara C, see Finegold H
ALPHA1A-ADRENERGIC RECEPTOR GENE Makita T, Yoshitomi O, Maekawa T, Ohtake K, see Ishida K
PROMOTER: DEMONSTRATION OF CELL- Sumikawa K, CONTINUOUS RESPIRATORY Okamoto H, see Kimotsuki H
SPECIFICITY AND REGULATION BY MANAGEMENT WITH A TRANSPORT Okamura H, Oguri K, Kawase K, Kitagawa T,
HYPOXIA, S-22 VENTILATOR FOR THE PATIENTS AFTER Fujiwara Y, CAUDAL ANALGESIA
Miguel RV, see Soto RG CARDIAC SURGERY, S-82 MODIFIES THE EFFECT OF FLUMAZENIL
Yeatman TJ, Marcet JE, Walker A, A Nakatani T, Kushizaki H, Kanata K, Hiruta H, Saito ON RECOVERY FROM SEVOFLURANE
PROSPECTIVE, RANDOMIZED TRIAL OF Y, THE INFLUENCE OF EPIDURAL ANESTHESIA AFTER ORAL MIDAZOLAM
THREE PERIOPERATIVE ANESTHETIC ANESTHESIA ON THE INTRAVENOUS PREMEDICATION, S-227
TECHNIQUES IN PATIENTS UNDERGOING INDUCTION WITH PROPOFOL, S-291 Okano N, see Yoshikawa D
BOWEL RESECTION, S-201 Nakatsuka H, see Yokoyama M Oku S, Katayama H, Morita K, METHICILLIN-
Millar S, Booth JV, Muir HA, A PRELIMINARY Nakatsuka M, Zhu J, DOES PRIOR RESISTANT STAPHYLOCOCCUS AUREUS
LOOK AT BETA2 ADRENERGIC PERCUTANEOUS TRANSLUMINAL IN A GENERAL ICU IN JAPAN: FIVE YEAR
POLYMORPHISMS AND UTERINE CORONARY ANGIOPLASTY AND / OR SURVEY, S-74
QUIESENCE, S-276 STENT INSERTION CHANGE CARDIAC Orkin FK, THE CHARLSON COMORBIDITY
Milliken JC, see Rosenbaum A MORTALITY OF SURGERY ON FEMORAL SCORE AS AN ALTERNATIVE TO THE ASA
see Rosenbaum A PSEUDOANEURYSM, COMPLICATED PHYSICAL STATUS CLASSIFICATION, S-
Minogue SC, Corcoran T, Fanning R, Shorten G, THE FROM CARDIAC CATHETERIZATION, S- 109
EFFECTS OF RANITIDINE, OMEPRAZOLE 115 see Polomano RC
AND PLACEBO ON INTRA OPERATIVE Naughton N, Greenfield MV, Welch KB, Benedict P, see McQuillan PM
GASTRO-OESOPHAGEAL REFLUX IN O'Reilly M, Rosenberg J, THE see McQuillan PM
PATIENTS WITH SYMPTOMS OF REFLUX, RELATIONSHIP BETWEEN SELECTED Osborn I, see Lewis A
S-90 RISK FACTORS AND ADVERSE Oshibuchi M, see Hara T
Mitsuyo T, Adachi N, Arai T, THE RELATIONSHIP OUTCOMES IN PATIENTS UNDERGOING Ouyang Y, see Giffard RG
BETWEEN DOPAMINERGIC THORACIC, OTOLARYNGOLOGIC, Ozaki M, see Nagata O
NEUROTRANSMISSION INNERVATION ORTHOPAEDIC, UROLOGIC, AND Ozcan B, see Yilmazlar A
AND DEXAMETHASONE-INDUCE GENERAL SURGERIES, S-108 Ozdilmac I, see Salihoglu Z
AGGRAVATION OF ISCHEMIC NEURONAL see Bullough AS Ozturk C, see Yilmazlar A
DAMAGE IN THE RAT STRIATUM, S-233 Nauss MD, see Greenfield MV see Yilmazlar A
Miyako M, see Fukusaki M Nemeth C, see Cook RI Pablo CS, see Munir MA
Miyao H, see Kawasaki J Nesargi S, see Jahr JS Paisansathan C, see Hoffman WE
see Kodaka M Nesbitt JJ, see Breukelmann D Weinberg G, Palmer J, Hoffman W,
Miyawaki T, see Kohjitani A Newman MF, see Bar-Yosef S DIFFERENTIAL EFFECTS OF
Mizobuchi S, see Yokoyama M see Welsby IJ BUPIVACAINE ON MITOCHONDRIAL
Mohajer P, Biyani A, Kroin JS, Tuman KJ, Lubenow Nguyen N, see Gyermek L RESPIRATION IN RAT BRAIN AND RAT
TJ, EFFICACY OF CERVICAL EPIDURAL see Gyermek L HEART, S-170
STEROID INJECTIONS IN PATIENTS WITH see Gyermek L Palacios M, see Urdaneta F
AXIAL AND RADICULAR PAIN, S-277 Nguyen NB, see Lee C Palmer J, see Paisansathan C
Mohiuddin R, see Cohen S Nicolau RR, see Aggarwal S Palmer L, see Norton J
see Cohen S Nicolau-Raducu R, see Hilmi IA Panchal S, Diwan S, Eliazo RF, Hemmings HC,
Mohr J, see Vohra P Niemann CU, see Krombach J SYMPTOMATIC TREATMENT OF CHRONIC
Mok MS, see She S Nishi S, see Kariya N LOW BACK PAIN: DETERMINATION OF
Monk TG, see Praetel C Nishihara F, ADJUSTMENT OF ANESTHESIA OPTIMAL SIGNAL FREQUENCY AND
Montes FR, see Kling JC DEPTH BY BISPECTRAL INDEX PRELIMINARY EFFICACY OF A
Mori T, Arai T, Yamashita M, DIRECTION OF THE ELONGATED SEIZURE DURATION IN TARGETED NON-INVASIVE ELECTRONIC
NEEDLE INSERTION IN AN INTERNAL ELECTROCONVULSIVE THERAPY, S-131 PAIN CONTROL DEVICE, S-213
JUGURAR VEIN PUNCTURE, Nishiyama T, Hanaoka K, COMPARISON Pandit JJ, DOES READ’S REBREATHING
RADIOGRAPHIC CONSIDERATION, S-221 BETWEEN A-LINE ARX INDEX AND TECHNIQUE OVERESTIMATE THE
Moric M, see Parnass SM BISPECTRAL INDEX DURING PROPOFOL- VENTILATORY RESPONSE TO CO2?, S-29
see Buvanendran A FENTANYL-NITROUS OXIDE Marfin AG, Hames K, Popat MT,
see Buvanendran A ANESTHESIA, S-130 TRACHEAL INTUBATION IN SIMULATED
Morimoto Y, see Ishida K Hanaoka K, SPINALLY MEDIATED GRADE III DIFFICULT LARYNGOSCOPY:
Morin AM, see Kranke P ANALGESIC INTERACTION BETWEEN COMPARISON OF SINGLE-USE PLASTIC
Morisaki H, see Takagi EN CLONIDINE AND BUPIVACAINE IN AND MULTIPLE-USE GUM ELASTIC
Morita K, see Oku S ACUTE THERMALLY OR INFLAMMATORY BOUGIE, S-42
see Yokoyama M INDUCED PAIN IN RATS, S-192 Hames K, Marfin AG, Popat M, Yentis SM,
Morita T, see Yoshikawa D Nisimaru N, see Kitano T TRACHEAL INTUBATION IN SIMULATED
Mortier E, see Van Aken J Noguchi T, see Kitano T GRADE III DIFFICULT LARYNGOSCOPY:
Muir HA, see Schultz JR Norton J, Karan S, Ward DS, Palmer L, Voter WA, COMPARISON OF THE FIBREOPTIC SCOPE
see Millar S Bailey PL, THE EFFECTS OF SEDATIVE AND PLASTIC BOUGIE, S-43
Munir MA, Jaffar M, Pablo CS, Zhang J, ROLE OF DOSES OF PROPOFOL OR MIDAZOLAM Dobson M, Rogers R, Saeed N, Carls P,
SELECTIVE CYCLOOXYGENASE-2 REDUCING BLOOD LOSS DURING
2003; 96; S-1–S-293
BIMAXILLARY OSTEOTOMY: CASE Ramachandran S, Lehning EJ, Wasnick JD, Rivera J, see Chaudhuri K
SERIES OF HYPOTENSIVE ANESTHESIA, DIPHENHYDRAMINE ATTENUATES THE Rizvi KA, see Maroof M
S-62 HEMODYNAMIC CHANGES ASSOCIATED Robinson MB, Sastry S, Lemmens HJ, Brock-Utne JJ,
Satya-Krishna R, McQuay H, A WITH PROTAMINE ADMINISTRATION, S- UNPREDICTABLE POTASSIUM CHANGES
COMPARISON OF THE COMPLICATION 56 IN DONATED BLOOD FOLLOWING
RATE ASSOCIATED WITH SUPERFICIAL Lehning EJ, Lagasse RS, FACTORS WARMING, S-124
VERSUS DEEP (OR COMBINED) BLOCK CONTRIBUTING TO HUMAN ERRORS BY Rocereto T, see Domsky R
FOR CAROTID ENDARTERECTOMY, S-279 ANESTHESIA PROVIDERS, S-102 Roche T, Royston D, THE RAPIDPOINT HEPARIN
Panicucci E, see Cattano D Ramananathan S, see Finegold H MANAGEMENT TIME (HMT) IS NOT
Paolicchi A, see Cattano D Ramanathan S, STATION OF THE PRESENTING PROLONGED BY APROTININ FOLLOWING
Pappas G, see Lu Y PART VS CERVICAL DILATATION AT THE HEPARIN DOSES USED PRIOR TO
Parekh UR, Splinter W, A RETROSPECTIVE TIME OF EPIDURAL BLOCK AS CARDIOPULMONARY BYPASS BUT IS BY
REVIEW OF PERIOPERATIVE FRESH PREDICTORS OF CESAREAN DELIVERY, HEMODILUTION WITH COLLOID, S-54
FROZEN PLASMA TRANSFUSION S-187 Rodger IW, see Buvanendran A
PRACTICE IN A CHILDREN'S HOSPITAL, Rao JH, TUMESCENT LOCAL ANESTHESIA, S- Rodriguez R, see Tse J
S-223 283 Roewer N, see Kranke P
Park KW, THE RISK OF PERIOPERATIVE Rawal S, see Recart A Rogers R, see Pandit JJ
CARDIAC COMPLICATIONS IS HIGH IN see Recart A Rosenbaum A, Wu WY, Parker LW, Ages BJ, Milliken
MAJOR VASCULAR SURGERY see Recart A JC, Breen PH, NOVEL BENCH VALIDATION
PERFORMED WITHIN A MONTH OF Rebecchi M, see Sawas A OF A NEW, FAST-RESPONSE AIRWAY
CORONARY ARTERY BYPASS GRAFT Recart A, Rawal S, White P, Macaluso A, Thornton L, SENSOR OF HUMIDITY AND
SURGERY (CABG): A CASE-CONTROL EFFECT OF LABETALOL ON SEIZURE TEMPERATURE, S-119
STUDY, S-38 ACTIVITY AFTER ELECTROCONVULSIVE Wu WY, Parker LW, Ages BJ, Milliken JC,
Park S, Rhee K, Ahn W, Bahk J, Do S, Lee K, THE THERAPY, S-8 Breen PH, CAN AIRWAY HUMIDITY
PROPHYLACTIC EFFECT OF Rawal S, White PF, Byerly S, Thornton L, SENSOR THERMOCOUPLES BE
DEXAMETHASONE ON POSTOPERATIVE THE EFFECT OF REMIFENTANIL ON CALIBRATED IN TEMPERATURE-
SORE THROAT, S-274 SEIZURE DURATION DURING CONTROLLED WATER BATHS?, S-120
Parker LW, see Rosenbaum A ELECTROCONVULSIVE THERAPY (ECT), Rosenberg AL, see Greenfield MV
see Rosenbaum A S-9 see Turner CR
Parnass SM, Wernikoff L, Blum SL, Moric M, see Hamza MA Rosenberg J, see Naughton N
Kornblatt I, INTERSCALENE BLOCKS FOR Gasanova I, White PF, Wang A, Jones S, Roth R, see Lewis A
OUTPATIENT SHOULDER SURGERY: A EFFECT OF AEP MONITORING ON Rothenberg SJ, see Johnson C
REVIEW OF EXPERIENCE WITH A SINGLE INTRAOPERATIVE DRUG USAGE AND see Jahr JS
SURGEON IN A COMMUNITY TEACHING RECOVERY AFTER INPATIENT SURGICAL see Jahr JS
HOSPITAL, S-280 PROCEDURES: A CLINICAL UTILITY see Lewis K
Patel KM, see Verghese ST STUDY, S-127 Roy RJ, EVALUATION OF A CARDIAC OUTPUT
Patti M, see Krombach J Rawal S, White P, Stool L, Thornton L, IS MONITOR (NICO) DURING AORTIC
Paulsen A, Houchin K, A LABORATORY STUDY THE BISPECTRAL INDEX USEFUL IN ANEURYSM REPAIR, S-138
OF GAS DIFFUSION THROUGH AN PREDICTING SEIZURE TIME AND Royston D, see Grattan A
ELLIPTICAL CUFF OF A LARYGEAL AWAKENING AFTER see Roche T
MASK AIRWAY, S-160 ELECTROCONVULSIVE THERAPY?, S-128 Runciman W, see Seiden S
Pelati E, see Cattano D see Gasanova I Ryu H, Kim D, Seo K, Ahn W, CARBON DIOXIDE
Pelligrini F, see Krombach J Klein K, White PF, Issioui T, Shah M, LEVELS IN THE OPERATING ROOM
Pentyala S, see Sawas A EFFECT OF CELECOXIB PREMEDICATION DURING GYNECOLOGICAL
see Adsumelli R ON RECOVERY AFTER OUTPATIENT LAPAROSCOPIC SURGERY, S-123
Perretta S, see Krombach J SURGERY: A DOSE RANGING STUDY, S- Sabry MM, see Michael R
Petrich S, see Waibel HA 195 Sabzevar F, see Fang Z
Petrovic V, see Singbartl G see Coloma M see Fang Z
Philips-Bute B, see Welsby IJ Reinsel R, see Veselis R Saeed N, see Pandit JJ
Phillips-Bute B, see Schultz JR Reves JG, see Havidich JE Saito M, see Yoshimura M
Picillo K, see Kovac A Reynolds J, see Schultz JR see Shibata O
Pino S, see Kling JC Rhee K, see Park S Saito S, see Kawahara F
Pivalizza EG, Wenzel MP, SONOCLOT ANALYSIS Rhodes SS, see Riess ML Saito Y, see Nakatani T
IN NEUROSURGICAL PATIENTS, S-173 Rich GF, see de Klaver MM Sakabe T, see Ishida K
Planinsic R, see Aggarwal S Richards TA, Fields AM, Ibrahim IN, Kaye AD, Salem M, see Hu G
Polomano RC, Orkin FK, Gordin V, Harvey HA, FELINE PULMONARY VASCULAR see Megally M
Mannes AJ, Carr DB, COMPARING RESPONSES TO EPHEDRINE, S-228 see El-Orbany MI
QUALITY OF LIFE IN PATIENTS WITH Fields AM, Ibrahim IN, Kaye AD, Salihoglu Z, Demiroluk S, Demirkiran O,
CANCER-RELATED PAIN AND CHRONIC ANALYSIS OF THE GABAA RECEPTOR Cakmakkaya S, Kose Y, THE EFFECTS OF
NONMALIGNANT PAIN USING THE AGONIST, MUSCIMOL, IN THE PATIENT POSITIONING ON RESPIRATORY
TREATMENT OUTCOMES IN PAIN PULMONARY VASCULAR BED OF THE MECHANICS ON SEVERE COPD PATIENTS
SURVEY (TOPS), S-212 CAT, S-229 DURING PNEUMOPERITONEUM, S-143
see McQuillan PM see Fields AM see Demiroluk S
see McQuillan PM see Fields AM Demirkiran O, Demiroluk S, Kose Y, Kaya
Popat M, see Pandit JJ Riedel BJ, see Grattan A G, NEUROMUSCULAR EFFECTS OF
Popat MT, see Pandit JJ Rieder J, see Lirk P ROCURONIUM IN PATIENTS WITH
Praetel C, Banner MJ, Monk TG, Gabrielli A, see Lirk P PARKINSON DISEASE, S-270
POSITIVE PRESSURE VENTILATION AND Riess ML, see Kevin LG Salihoglu Z, Altintas F, Ozdilmac I, Demiroluk SI,
ISOFLURANE INCREASE PHYSIOLOGIC Kevin LG, Camara AK, Rhodes SS, Stowe Uzun H, THE EFFECTS OF EPIDURAL
DEADSPACE VOLUME (VDPHYS) IN DF, HYPOTHERMIA INCREASES ANESTHESIA WITH 0.25 % BUPIVACAINE
PATIENTS RECEIVING GENERAL MITOCHONDRIAL CA2+ BUT ATTENUATES ON THE NEUROENDOCRINE RESPONSE
ANESTHESIA, S-44 MITOCHONDRIAL CA2+ OVERLOAD TO MAJOR ABDOMINAL SURGERY, S-290
Prasad A, see Cohen S DURING MYOCARDIAL ISCHEMIA AND Sandberg EH, see Sharma R
Prieto I, see Fortier JD REPERFUSION IN GUINEA PIG INTACT Sandberg WS, see Sharma R
see Fortier JD HEARTS, S-18 Sanderson IC, Gilbert W, Valles J, SECURE ACCESS
Prieto J, see Gonzalez R Riles T, see Bekker A TO ANESTHESIA RECORDS AND
Quarnstrom K, see Blum SL Rimmer M, see Van Den Kerkhof EG OPERATING ROOM SCHEDULES USING
Quinlan J, see Hilmi IA Rinne T, see Waibel HA AN INTERNET BROWSER, S-116
Quoss A, see Singbartl G Klösel S, Waibel HA, Hall BA, Bremerich Valles J, Cory R, Hollowell L, Alexander L,
Rafizadeh M, Lele A, Dorian R, THE EFFICACY OF DH, COMPARISON OF LEVOBUPIVACAINE THE USE OF AN INTERNET-BASED
REMIFENTANIL IN AMBULATORY 0,16% AND S-ROPIVACAINE 0,16% PHARMACY BILLING SYSTEM WITH AN
PATIENTS, S-10 COMBINED WITH SUFENTANIL 0,5µG/ML AUTOMATED ANESTHESIA RECORD, S-
Raiga J, see Meyer A FOR PARTURIENT-CONTROLLED 117
EPIDURAL LABOR ANALGESIA, S-184 Sandin R, see Lennmarken C
2003; 96; S-1–S-293
Sapien RL, see Johnson C Singbartl G, Schleinzer W, Munkel H, RATIONAL see Novalija E
Sasano H, see Ito S MEDICAL DECISION MAKING IN see Riess ML
Sasano N, see Ito S AUTOLOGOUS TRANSFUSION IMPROVES Struemper D, see Herroeder S
Sastry S, see Robinson MB EFFICACY AND COST-EFFICIENCY, S-110 Strum DP, May JH, Vargas LG, CODING
Satya-Krishna R, see Pandit JJ Schueler K, Munkel H, ONLY TWO PERMUTATIONS MAY BE REDUCED
Sawas A, Rebecchi M, Pentyala S, CALORIMETRIC CLINICAL PARAMETERS ARE OF PRIOR TO MODELING OF DUAL
MEASUREMENTS OF BINDING OF DECISIVE IMPACT ON INCREASE IN PROCEDURE SURGERIES, S-106
VOLATILE ANESTHETICS TO SERUM TOTAL RBC-MASS BY PRE-OPERATIVE May JH, Vargas LG, FACTORS
ALBUMIN, S-246 AUTOLOGOUS BLOOD DONATION – A AFFECTING THE VARIABILITY OF TIME
Schabel J, see Adsumelli R PROSPECTIVE STATISTICAL ANALYSIS IN ESTIMATES FOR DUAL PROCEDURE
Schaeffer C, see Meyer A 704 PATIENTS, S-111 SURGERIES, S-107
Schaeffer R, see Meyer A Schnelle M, Munkel H, Quoss A, Struys M, see Van Aken J
Scheld HH, see Jahn UR ADOPTING PREOPERATIVE Stubbe H, see Westphal M
Scher CS, CONTINOUS OXYGEN INSUFFLATION AUTOLOGOUS BLOOD DONATION TO Sugahara K, see Nakamura S
(SWINE): AN ADDITIONAL TOOL FOR THE PHYSIOLOGIC BASICS OF Sullivan E, see Hilmi IA
FAILED INTUBATION, S-80 ERYTHROPOIESIS IMPROVES INCREASE Sumikawa K, see Hara T
Schleinzer W, see Singbartl G IN TOTAL RBC MASS, S-112 see Yoshimura M
Schneider B, see Hamza MA Petrovic V, Munkel H, PERI-OPERATIVE see Fukusaki M
Schnelle M, see Singbartl G BLOOD SALVAGE: THE QUALITY- see Nakamura T
Schobersberger W, see Lirk P PROBLEM OF THE LAST, INCOMPLETELY- see Takada M
Scholz PM, see Tse J FILLED LATHAM BOWL - ANALYSIS OF see Shibata O
Schroeder A, see Blum SL ELIMINATION OF BY-PRODUCTS BY THE Sumita S, see Fujisawa T
Schroeder DR, see Sprung J COMPLETELY AND INCOMPLETELY- Fujisawa T, Unruh GK, Benson KT, Goto H,
Schueler K, see Singbartl G FILLED DISCONTINUOUSLY-PROCESSING DIRECT EFFECTS OF ROPIVACAINE AND
Schuler H, see McQuillan PM LATHAM-BOWL-SYSTEM AND THE BUPIVACAINE ON SYMPATHETIC NERVE
Schultz JR, Muir HA, Greenfield J, Phillips-Bute B, CONTINUOUSLY-PROCESSING ACTIVITY IN RABBITS, S-25
White W, Reynolds J, COMPARING ECGS CHAMBER-SYSTEM, S-113 Summer G, see Lirk P
GENERATED FROM A NOVEL STERNAL Singbartl K, see Menzebach A Suzuki T, see Ueta K
DEVICE TO TRACINGS PRODUCED BY Singhal V, see Maroof M Svensén CH, see Hahn RG
THE BACKPAD ECG AND A STANDARD Sivjee K, see Urban MK Taboada M, Helgeson L, Bustos A, Aouad R,
THREE LEAD ECG, S-150 Slack M, see Verghese ST Atanassoff PG, SEDATION WITH
Schumacher MA, Eilers H, MECHANICALLY Slagle JM, see Weinger MB SEVOFLURANE OR PROPOFOL IN
ACTIVATED ION CHANNELS IN PAIN Sliwinski M, see Greenfield MV PATIENTS UNDERGOING REGIONAL
TRANSDUCTION, S-194 Small RH, see Gust AM ANESTHESIA FOR ORTHOPEDIC
Schwinn DA, see Michelotti G Smith A, see Grattan A SURGERY, S-259
Sear JW, Giles J, CHRONIC BETA- Smith BE, see Yang H see Kurup VJ
ADRENOCEPTOR BLOCKADE DOES NOT Smith KN, Kopacz DJ, McDonald SB, SPINAL Takada M, Fukusaki M, Terao Y, Kanaide M,
MINICK ACUTE MEDICATION IN ITS CHLOROPROCAINE, S-285 Yamashita K, Sumikawa K, PRE-
EFFECTS ON CARDIAC OUTCOME, S-261 Smith MP, see Michelotti G ADMINISTRATION OF LOW-DOSE
Sehgal R, see Kumar R Soaita A, see Aggarwal S KETAMINE ATTENUATES TOURNIQUET
Seiden S, Kivlahan C, Runciman W, Christansen U, see Hilmi IA PAIN IN HEALTHY VOLUNTEERS, S-198
Barach P, WRONG SIDED ANESTHETIC Soldin S, see Verghese ST Takagi EN, Kotake Y, Serita R, Morisaki H, Takeda J,
AND SURGICAL PROCEDURES: ARE Solvason HB, see Chandel AP MONITORING PLATELET AGGREGATION
THEY PREVENTABLE?, S-101 Sonoda S, THE EFFECT OF FENTANYL ON DEFECT INDUCED BY
Sekikawa T, see Mamiya K RENAL TUBULAR FUNCTION AND CARDIOPULMONARY BYPASS:
Sengoku K, see Mamiya K NDOCRINE RESPONSE DURING COMPARISON BETWEEN NOVEL WHOLE
Seo K, see Ryu H THORACOTOMY, S-264 BLOOD AGGREGOMATER AND
Serita R, see Takagi EN Soremeken O, see Cohen S SONOCLOT ANALYZER, S-55
Serrano C, see Gonzalez R Soro M, see Aguilar G Takahata O, see Mamiya K
see Gonzalez R Soto RG, see Vila Jr. H Takeda J, see Takagi EN
see Gonzalez R Fu ES, Vila Jr. H, Miguel RV, DOES Takei H, see Kawasaki J
Sethi M, see Kumar R NASAL CAPNOGRAPHY IMPROVE Talja P, see Viertiö-Oja H
Shah M, see Recart A PATIENT SAFETY DURING MAC?, S-147 Talke P, see Stapelfeldt CK
Shakhar G, see Bar-Yosef S see Horowitz PE Tan H, see Chiu J
Shanks A, see Greenfield MV Souders JE, Bishop MJ, Domino KB, Khuri S, Tan JW, see Chiu J
Sharma R, Sandberg EH, Wiklund R, Sandberg WS, Henderson WG, Daley J, ROLE OF Tan S, see Bilgin H
INFORMATION OVERLOAD: DO ANESTHETIC CARE IN UNEXPECTED Tanaka KA, see Kawasaki J
ANESTHESIOLOGISTS EXCEED PATIENTS' PERIOPERATIVE DEATHS IN VETERANS Tang J, see Ma H
CAPACITY TO LEARN?, S-100 AFFAIRS HOSPITALS, S-104 Ma H, White PF, Wender RH, DOES
Shaw A, see Grattan A Splinter W, see Parekh UR CEREBRAL MONITORING IMPROVE
She S, Xu X, Mok MS, Xu L, Chen C, Liu C, RELIEF Splinter WM, see Chowdary KM RECOVERY AFTER AMBULATORY
OF UTERINE ARTERY ENBOLIZATION Sprung J, Girgenti GT, Warner M, Schroeder DR, ANESTHESIA? A COMPARISON OF BIS
PAIN BY PATIENT CONTROLLED Christopher BM, Warner DO, CARDIAC AND AEP MONITORING DEVICES, S-5
EPIDURAL ANALGESIA WITH DIFFERENT ARRESTS DURING ANESTHESIA FOR Tang Y, see Yem JS
MIXTURES, S-211 NONCARDIAC SURGERY: REVIEW OF Yem JS, Turner MJ, Baker BA, THE
Shibata O, see Yoshimura M 518,249 ANESTHETICS BETWEEN 1990- COMPARISON OF DIFFERENT
Saito M, Yoshimura M, Yamaguchi M, 2000 IN A TERTIARY REFERRAL CENTER, CALIBRATION METHODS FOR
Makita T, Sumikawa K, INTERACTIONS OF S-37 PNEUMOTACHOGRAPH, S-149
EDROPHONIUM WITH NEOSTIGMINE IN Tungpalan L, Whalley DG, Tommaso F, Tang Z, see Jahr JS
THE RAT TRACHEA, S-240 EFFECTS OF WEIGHT AND MODE OF Tantawy H, see Akhtar S
Shiga T, Murray PA, Damron DS, PROPOFOL VENTILATION ON RESPIRATORY SYSTEM see Akhtar S
INCREASES CONTRACTILITY DURING MECHANICS AND OXYGENATION Taylor IR, see Bullough AS
ENDOTHELIN-1 AND ANGIOTENSIN II DURING LAPAROSCOPY, S-81 Tcherven N, Yondov D, Worley S, Tetzlaff J, BLOOD
RECEPTOR ACTIVATION IN RAT Stafford-Smith M, see Welsby IJ VOLUME INCREASE BY HYPERTONIC
CARDIOMYOCYTES, S-33 Stapelfeldt CK, Brown R, Lobo E, Talke P, SALINE ADMINISTRATION PREVENTS
Shimada M, see Kohjitani A INTRAOPERATIVE DEXMEDETOMIDINE SYSTEMIC HYPOTENSION AFTER SPINAL
Shorten G, see Minogue SC INDUCED VASOCONSTRICTION, S-256 ANESTHESIA, S-286
Shorten GD, see Ghori K Stein C, see Kopf A Templeton T, see Bryan Y
see Ghori K Stice-Beredino LL, Fahey, III T, Dhar P, see Bryan Y
Sia AT, see Chiu J DEXMEDETOMIDINE SEDATION DURING Tenkanen N, see Viertiö-Oja H
Silverman DG, see Akhtar S REGIONAL ANESTHESIA: A PILOT Terao Y, see Takada M
see Akhtar S STUDY, S-13 Terui K, PERINATAL MANAGEMENT OF
Silverstein J, see Feierman DE Stool L, see Recart A ANTENATALLY DIAGNOSED
Stowe DF, see Kevin LG
2003; 96; S-1–S-293
CONGENITAL DIAPHRAGMATIC HERNIA: MODEL OF ACUTE PULMONARY Walsh F, see Ghori K

SURVEY OF PRACTICE IN JAPAN, S-177 HYPERTENSION, S-31 see Ghori K
Tetzlaff J, see Tcherven N Urwyler A, see Girard T Wang A, see Recart A
Tham C, see Chen F Usuda T, see Uchida I see Yuan C
Theilmeier G, see Mersmann J Uzun H, see Salihoglu Z Wang L, see Bullough AS
see Menzebach A Uzun N, see Cohen S Wang Y, see Lu Z
Thomas J, see Horowitz PE see Cohen S Ward DS, see Norton J
Thomas T, see Gasanova I Valdez N, see Urdaneta F Warner DO, see Sprung J
Thornton L, see Recart A Valdivieso E, see Gonzalez R Warner DS, see Homi HM
see Recart A Valles J, see Sanderson IC Warner M, see Sprung J
see Recart A see Sanderson IC Warshal D, see Khaleghi B
Tilghman BM, see Landrum AL Van Aken H, see Mersmann J Wasnick JD, see Ramachandran S
Tolvanen-Laakso H, see Viertiö-Oja H see Westphal M Weaver JM, Arron BL, Eleff SM, THE GAS USAGE
Toma G, Amcheslavski VG, Madorsky SV, DeWitt see Menzebach A MONITOR OF THE DATEX-OHMEDA S/5
DS, CEREBRAL OXYGEN METABOLISM see Westphal M ADU DIGITAL ANESTHESIA MACHINE
AND TRANSCRANIAL DOPPLER Van Aken H , see Jahn UR FACILITATES TEACHING OF CLOSED
ULTRASONOGRAPHY MONITORING IN Van Aken J, Verplancke T, De Baerdemaeker L, CIRCUIT ANESTHESIA, S-105
NEUROSURGICAL COMATOSE PATIENTS Struys M, Caemaert J, Mortier E, Weber C, see Kovac A
WITH UNFAVORABLE OUTCOME, S-68 CARDIOVASCULAR CHANGES DURING Wei L, see Ghori K
Tomita Y, see Ito S ENDOSCOPIC THIRD Weinberg G, see Hoffman WE
Tomiyasu S, see Hara T VENTRICULOSTOMY IN CHILDREN, S-172 see Paisansathan C
Tommaso F, see Sprung J Van Den Kerkhof EG, Goldstein DH, Blaine WC, Weinger MB, Barker E, Slagle JM, THE EFFECT OF
Trager G, see Hemmerling TM Rimmer M, VALIDATION OF AN READING ON THE VIGILANCE, CLINICAL
Tsai S, see Lee C ELECTRONIC VS A PAPER VERSION OF WORKLOAD, AND TASK DISTRIBUTION
Tse J, Zhang S, Scholz PM, Rodriguez R, Weiss HR, THE SELF-COMPLETED PRE-ADMISSION OF ANESTHESIA PROVIDERS, S-99
CYCLIC GMP PHOSPHODIESTERASE ADULT ANESTHETIC QUESTIONNAIRE, S- Weiss HR, see Tse J
INHIBITION AND UNCOUPLING OF BETA- 3 Weitkamp B, see Menzebach A
ADRENERGIC RESPONSES IN RENAL Van der Starre PJ, see Chandel AP Welch KB, see Naughton N
HYPERTENSION-INDUCED CARDIAC Vargas LG, see Strum DP Welsby IJ, Newman MF, Philips-Bute B, Stafford-
HYPERTROPHY, S-34 see Strum DP Smith M, SYSTEMIC HYPOTENSION
Tubic G, see Gramlich L Verghese ST, Hannallah RS, Soldin S, ACCURACY AFTER PROTAMINE ADMINISTRATION IS
Tuman KJ, see Gramlich L OF NEEDLELESS SYSTEMS IN ASSOCIATED WITH IN-HOSPITAL
see Kroin JS INTRAVENOUS ADMINISTRATION OF MORTALITY FOLLOWING PRIMARY
see Kroin JS SMALL VOLUME DRUGS TO INFANTS CABG SURGERY, S-57
see Buvanendran A AND CHILDREN, S-152 Wen M, see Vohra P
see Buvanendran A Hannallah RS, Brennan MP, Yarvitz JL, Wender RH, see Ma H
see Buvanendran A Patel KM, NASAL ADMINISTRATION OF see Tang J
see Buvanendran A REMIFENTANIL IMPROVES CONDITIONS Wenzel MP, see Pivalizza EG
see Mohajer P FOR INSERTION OF A LARYNGEAL MASK Wernikoff L, see Parnass SM
Tungpalan L, see Sprung J AIRWAY (LMA) FOLLOWING Westphal M, Stubbe H, Daudel F, Van Aken H, Booke
Turner CR, Greenfield MV, Rosenberg AL, A SEVOFLURANE INDUCTION IN M, Bone HG, EMPLOYING DOPEXAMINE
SIMPLE METHOD FOR ASSESSING CHILDREN, S-219 AS A USEFUL AGENT TO REVERSE THE
KNOWLEDGE GROWTH DURING Hannallah RS, Cross RR, Slack M, Martin ARGININE VASOPRESSIN-ASSOCIATED
SUBSPECIALTY ANESTHESIA TRAINING, GR, AUSCULTATION OF BILATERAL DECREASE IN OXYGEN DELIVERY
S-95 BREATH SOUNDS DOES NOT RULE OUT DURING OVINE ENDOTOXEMIA, S-23
Turner MJ, see Yem JS ENDOBRONCHIAL INTUBATION IN Eletr D, Bone HG, Ertmer C, Van Aken H,
see Tang Y CHILDREN, S-220 Booke M, ARTERIOVENOUS
Tuzuner F, see Yilmaz AA Verplancke T, see Van Aken J CARBOXYHEMOGLOBIN DIFFERENCE IN
see Alanoglu Z Veselis R, Feshchenko V, Reinsel R, Lalmansingh A, CRITICAL ILLNESS: FICTION OR FACT?,
Uchida I, Kobayashi N, Usuda T, RELIABILITY Beattie B, Akhurst T, REGIONAL CBF IS S-78
FOR ASSESSMENT OF HEPATIC DECREASED IN DIFFERENT REGIONS OF Whalley DG, see Sprung J
FUNCTION USING ICG PULSE DYE THE BRAIN BY PROPOFOL AND Whipple J, see Akhtar S
DENSITOMETRY DURING HEPATIC THIOPENTAL AT EQUAL DRUG EFFECT, S- see Akhtar S
TRANSPLANTATION, S-151 245 White JL, see Manyam SC
Amata M, Maniwa Y, THE CHAOTIC Viertiö-Oja H, Maja V, Talja P, Tenkanen N, White P, see Recart A
ANALYSIS OF EEG CAN REFLECT DEPTH Tolvanen-Laakso H, Yli-Hankala A, see Hamza MA
OF ANESTHESIA, S-244 MONITORING ENTROPY OF THE see Recart A
see Ueta K COMPOSITE EEG AND FEMG SIGNAL White PF, see Ma H
Uchida J, PROPOFOL PROVIDES BETTER DURING GENERAL ANESTHESIA, S-135 see Tang J
ANESTHESIA THAN KETAMINE/ Vila Jr. H, Cantor AB, Mackey DC, Soto RG, see Recart A
DIAZEPAM SEDATION FOR FLORIDA OFFICE SURGERY AND see Recart A
TRANSVAGINAL OOCYTE RETRIEVAL AMBULATORY SURGERY CENTER see Gasanova I
WITHOUT ADVERSELY AFFECTING OUTCOMES FOLLOWING see Recart A
REPRODUCTIVE OUTCOME, S-176 IMPLEMENTATION OF OFFICE see Coloma M
see Kodaka M REGULATIONS, S-4 White RD, see McGlinch BP
Ueta K, Suzuki T, Uchida I, Mashimo T, LOCAL see Soto RG White W, see Schultz JR
ANESTHETICS INHIBIT THE 5-HT3 Vogt MT, see Williams BA Wiklund R, see Sharma R
RECEPTOR VIA DIFFERENT Vohra P, Daugherty C, Wen M, Mohr J, Barach P, Williams BA, Vogt MT, Figallo CM, Francis KA,
MECHANISMS AND SITES OF ACTION, S- EVALUATION OF HOUSESTAFF AND Kentor ML, Harner CD, OUTCOMES AFTER
252 MEDICAL STUDENT ATTITUDES ACL RECONSTRUCTION: THE EFFECT OF
Ullrich K, see Ghori K TOWARDS ADVERSE MEDICAL EVENTS, FEMORAL NERVE BLOCK ANALGESIA, S-
Unruh GK, see Sumita S S-103 293
Urban MK, Jules-Elysee K, Beckman J, Sivjee K, Voronkov E, see Girard T Worley S, see Tcherven N
King T, Kelsey W, PULMONARY INJURY IN Voter WA, see Norton J Wu D, see Blum SL
PATIENTS UNDERGOING COMPLEX SPINE Votta-Valis G, see Lu Y Wu V, see Ansley DM
SURGERY, S-75 Waibel HA, see Rinne T Wu WY, see Rosenbaum A
Beckman J, Wukovits B, Kelsey W, Petrich S, Rinne T, Hall BA, Bremerich DH, see Rosenbaum A
INTRATHECAL CLONIDINE DID NOT BACKGROUND INFUSION ADDED TO Wukovits B, see Urban MK
IMPROVE POSTOPERATIVE PAIN PARTURIENT CONTROLLED EPIDURAL Xia F, see Xia Z
MANAGEMENT AFTER COMPLEX SPINE ANALGESIA DURING LABOUR AND Xia R, see Xia Z
SURGERY, S-206 DELIVERY - IS LESS MORE?, S-186 Xia Z, see Ansley DM
Urdaneta F, Valdez N, Bonnel M, Palacios M, Kirby Waldrop KS, see Hahn RG Gu J, Ansley DM, Xia F, Yu J,
D, Lobato E, EFFECTS OF A SILDENAFIL Walker A, see Miguel RV ANTIOXIDANT THERAPY DECREASES
ANALOG; UK343-664, ON A PORCINE Walsh EP, see Kussman BD PLASMA ENDOTHELIN-1 AND
2003; 96; S-1–S-293
THROMBOXANE B2 AFTER CARDIAC SURGERY AND

CARDIOPULMONARY BYPASS IN HEPATOSPLANCHNIC HYPOPERFUSION,
PATIENTS WITH CONGENITAL HEART S-59
DISEASE, S-51 Yoshimura M, Shibata O, Yamaguchi M, Saito M,
see Ansley DM Makita T, Sumikawa K, EFFECT OF
Xia R, Yang G, Xia Z, Hou W, APROTININ SELEGILINE ON THE CONTRACTILE AND
REDUCES INTERLEUKIN-8 PRODUCTION PHOSPHATIDYLINOSITOL RESPONSES OF
AND LEUKOCYTE INFILTRATION AFTER RAT TRACHEA, S-28
CEREBRAL ISCHEMIA-REPERFUSION IN see Shibata O
A RABBIT MODEL, S-235 Yoshitomi O, see Hara T
see Xia Z see Nakamura T
Xie X, see Megally M Younan N, see Michael R
Xu L, see She S Yu B, see Fan Q
Xu X, see She S see Fan Q
Yamaguchi H, see Aoki T see Fan Q
Yamaguchi M, see Yoshimura M see Lu Z
see Shibata O Yu J, see Xia Z
Yamak B, see Yazicioglu H Yuan C, Wang A, Mehendale S, Maleckar S, Ang-Lee
Yamashita K, see Takada M M, MODULATION OF VALERIAN ON
Yamashita M, see Mori T BRAINSTEM GABAERGIC EFFECTS IN
Yang G, see Xia Z RATS, S-232
Yang H, Homi HM, Smith BE, Grocott HP, Yuan S, EFFECTS OF HYPERTONIC-
CARDIOPULMONARY BYPASS REDUCES HYPERONCOTIC SOLUTION ON THE
THE MAC OF ISOFLURANE IN THE RAT, S- CELL VOLUME AND VIABILITY OF
35 HUMAN UMBILICAL VEIN ENDOTHELIAL
Lee Y, Kim J, Han S, EFFECTS OF CELLS TO HYPOXIA AND
PHENYTOIN ON ROCURONIUM-INDUCED REOXYGENATION, S-71
NEUROMUSCULAR BLOCKADE ON RAT Zaentz A, see Ma H
HEMIDIAPHRAGM PREPARATION, S-238 Zhang J, see Munir MA
Yarvitz JL, see Verghese ST Zhang S, see Tse J
Yazicioglu H, Yildiz-Muslu S, Yamak B, Erdemli O, Zhu J, see Nakatsuka M
LARINGEAL MASK AIRWAY INSERTION
WITH REMIFENTANIL, S-266
Yeatman TJ, see Miguel RV
Yem JS, Tang Y, Turner MJ, Baker BA, SOURCES
OF ERROR IN NON-INVASIVE
PULMONARY BLOOD FLOW
MEASUREMENTS BY PARTIAL RE-
BREATHING: A COMPUTER MODEL
STUDY, S-141
see Tang Y
Yentis SM, see Pandit JJ
Yeo IS, see Chiu J
Yeo S, see Chin K
Yeomans D, see Lu Y
Yildiz-Muslu S, see Yazicioglu H
Yilmaz AA, Karabayirli S, Korkmaz T, Ates Y,
Tuzuner F, PATIENT-CONTROLLED
SEDATION AND ANALGESIA WITH
REMIFENTANIL-PROPOFOL FOR SHOCK
WAVE LITHOTRIPSY; HAVE WE REACHED
OUR ULTIMATE GOAL IN PATIENT
COMFORT AND SAFETY?, S-11
see Alanoglu Z
Yilmazlar A, Kuruefe R, Ozcan B, Aydinli U, Ozturk
C, DIFFERENT CONTINUOUS TOTAL
INTRAVENOUS ANESTHESIA TECHNIQUE
IS RECOMMENDED FOR WAKE-UP TEST
(A PRELIMINARY STUDY), S-163
Kuruefe R, Aydinli U, Ozturk C, Kutlay O,
MIDAZOLAM-FLUMAZENIL VERSUS
PROPOFOL ANESTHESIA IN THE
SCOLIOSIS SURGERY, S-164
Kutlay O, Ilgaz O, CONTINUOUS SPINAL
ANESTHESIA WITH TWO DIFFERENT
CATHETERS IN ELDERLY, S-287
Kutlay O, Ilgaz O, CONTINUOUS SPINAL
ANESTHESIA WITH HYPERBARIC
BUPIVACAINE 3MG+ FENTANYL 10µG
FOR HEMIARTHROPLASTY IN THE
ELDERLY, S-288
Yli-Hankala A, see Viertiö-Oja H
Yokoo N, see Homi HM
Yokoyama M, Itano Y, Hanazaki M, Mizobuchi S,
Nakatsuka H, Morita K, EFFECTS OF
ELECTROACUPUNCTURE ON PAIN-
RELIEF AND THE DISTRIBUTION OF
LYMPHOCYTE SUBSETS IN PATIENTS
WITH CHRONIC LOW BACK PAIN, S-215
Yondov D, see Tcherven N
Yoshikawa D, Kawahara F, Kadoi Y, Goto F, Okano
N, Morita T, ELEVATED PLASMA
CONCENTRATONS OF THE MATURE
FORM OF ADRENOMEDULLIN DURING
ANESTH ANALG SUBJECT INDEX S304
2003; 96; S-1–S-293
Abdominal surgery, see Surgery piritramide, vs morphine, PCIA, S-202 propofol

Acetaminophen, see Analgesics remifentanil BIS during short surgical procedures, S-6
Acid-base equilibrium, acidosis effect on seizure duration during ECT, S-9 effect on contractility during endothelin-1 and
intracellular, effects on steady-state rates of creatine efficacy in ambulatory patients, S-10 angiotensin II receptor activation,
kinase, rat brain slices, S-171 nasal administration, facilitation of LMA rat cardiomyocytes, S-33
myocardial tissue, during ventricular fibrillation, insertion, children, S-219 induction using target-controlled infusion,
effect of bupivacaine, S-21 -propofol, PCSA with, for shock wave influence of epidural anesthesia, S-
Adenosine kinase inhibitors, see Pharmacology lithotripsy, S-11 291
Adhesion molecules, see Neutrophils Anatomy, skin landmarks, determination of point of mixture of propofol, alfentanil, and lidocaine
Adrenomedullin, see Sympathetic nervous system needle insertion in peripheral nerve blocks, for ophthalmic surgery under
Adverse events, housestaff and medical student S-282 MAC, S-12
attitudes, evaluation, S-103 Anemia, see Complications mixture of propofol, alfentanil, and lidocaine
urologic, relationship between selected risk factors Anesthesia, pediatric for sedation, ophthalmic
and adverse outcomes, S-108 appendectomy, efficacy of somatic paravertebral procedures, obese vs normal weight
AEP, see Monitoring, auditory evoked potential block for postoperative pain relief, S- patients, S-258
Age factors, elderly 226 propofol-fentanyl-N2O anesthesia, BIS vs A-
continuous spinal anesthesia aprotinin pharmacokinetics during CPB, small line ARX index during, S-130
comparison of two different catheters, S-287 patients, S-53 remifentanil-propofol, PCSA with, for shock
hyperbaric bupivacaine 3mg plus fentanyl congenital diaphragmatic hernia, antenatally wave lithotripsy, S-11
10µg for hemiarthroplasty, S-288 diagnosed, perinatal management, S- sedative doses, effects on upper airway
laparoscopic vs laparotomic cholecystectomy, 177 obstruction, S-275
effects of perioperative pulmonary delivery of normothermic blood and fluids, use of target blood concentration vs measured blood
function, S-64 dry heat warmer, S-153 concentration, pharmacokinetic
Airway endobronchial intubation, failure to diagnose by simulation, S-126
difficult, endotracheal intubation, evaluation using auscultation of bilateral breath sounds, vs enflurane, effects in corrective surgery of
Macintosh Video Laryngoscope, S-157 S-220 scoliosis with posterior
management, medical emergencies, use of endoscopic third ventriculostomy, cardiovascular instrumentation, S-63
prehospital rapid sequence intubation by changes during, S-172 vs ketamine/diazepam sedation, reproductive
paramedics, S-79 fresh frozen plasma, perioperative practice, S-223 outcome after transvaginal oocyte
smooth muscle, effect of selegiline, rat trachea, S- intravenous administration of small volume drugs, retrieval, S-176
28 accuracy of needleless systems, S-152 vs midazolam-flumazenil, scoliosis surgery, S-
upper LMA insertion, facilitation, nasal administration of 164
choking during dental treatment of intellectual remifentanil, S-219 vs sevoflurane, sedation, patients undergoing
disability, S-7 MRI under general anesthesia regional anesthesia for orthopedic
obstruction, effects of sedative doses of differences in tympanic and rectal temperature surgery, S-259
propofol or midazolam and changes, S-122 vs thiopental, effects on regional CBF in
hypoxia, S-275 incidence of hypothermia, S-224 different regions of brain, S-245
Airway sensor, see Equipment Anesthesia machines, see Equipment remifentanil
Alfentanil, see Analgesics Anesthesiologists LMA insertion, S-266
Alternative therapy, hemispheric synchronization, human errors by anesthesia providers, contributing methohexital and, for general anesthesia in
effect on amount of intraoperative analgesia factors, S-102 Third World countries, S-114
required, S-257 learning styles, S-96 -propofol, PCSA with, for shock wave
Analgesics patient education, information load, S-100 lithotripsy, S-11
acetaminophen, effects on pharmacokinetics of oral vigilance, clinical workload, and task distribution, thiopental, vs propofol, effects on regional CBF in
midazolam, S-262 effect of reading, S-99 different regions of brain, S-245
alfentanil, mixture of propofol, alfentanil, and Anesthetic preconditioning Anesthetics, local
lidocaine delayed, of endothelium, against cytokine-induced bupivacaine
ophthalmic surgery under MAC, S-12 cell death, S-15 clonidine and, spinally mediated interaction,
sedation, ophthalmic procedures, obese vs effects on latency to ischemic injury in isolated acute thermally or inflammatory
normal weight patients, S-258 hearts, S-14 induced pain, rats, S-192
fentanyl triggered by ROS, effects on mitochondrial ATP differential effects on mitochondrial
combined with levobupivacaine vs racemic synthesis and ROS formation after respiration, rat brain and rat heart,
bupivacaine, for cesarean section, ischemia, guinea pig hearts, S-16 S-170
S-185 Anesthetics, gases direct effects on sympathetic nerve activity,
effect on renal tubular function and endocrine nitrous oxide (N2O) rabbits, S-25
response during thoracotomy, S- diffusion through elliptical cuff of LMA, S-160 effect on myocardial tissue and acidosis during
264 propofol-fentanyl-N2O anesthesia, BIS vs A- ventricular fibrillation, S-21
hyperbaric bupivacaine 3mg plus fentanyl line ARX index during, S-130 epidural anesthesia with 0.25% bupivacaine,
10µg, continuous spinal anesthesia, xenon, neuroprotective effect during transient effects on neuroendocrine response
elderly patients, S-288 middle cerebral artery occlusion, mice, to major abdominal surgery, S-290
protection of stunned myocardium, dogs, S-20 S-167 hyperbaric bupivacaine 3mg plus fentanyl
morphine Anesthetics, intravenous 10µg, continuous spinal anesthesia,
intrathecal, continuous application in phantom dexmedetomidine elderly patients, S-288
pain, S-216 effects on reactive hyperemia and infarct size chloroprocaine, spinal, dose-response effects, S-285
intrathecal, -induced spastic paraparesis after following focal cerebral ischemia, differential inhibition of cyclic nucleotide-gated
non-injurious interval of spinal rats, S-165 channels, S-251
ischemia, effect of low-dose -induced vasoconstriction, intraoperative, S- inhibition of 5-HT3 receptor, mechanisms and sites
buprenorphine, rats, S-234 256 of action, S-252
PCA, vs postoperative epidural analgesia, -related hypotension following CABG, levobupivacaine
ultra-fast-track anesthesia in off- characterization and management, vs racemic bupivacaine, intrathecal
pump cardiac surgery, S-47 S-255 administration, for cesarean
single 7.5 mg IV dose, analgesic effect after sedation during regional anesthesia, S-13 section, S-185
radical prostatectomy, S-208 sedation for awake carotid endarterectomy, vs S-ropivacaine, for parturient-controlled
single 7.5 mg IV dose, analgesic effect rationale and safety, S-166 epidural labor analgesia, S-184
following total abdominal fentanyl, propofol-fentanyl-N2O anesthesia, BIS vs lidocaine
hysterectomy, S-207 A-line ARX index during, S-130 endotracheal, with dispersion steam for awake
single 7.5 mg IV dose, cardiovascular and ketamine extubation, S-162
respiratory effects, postoperative ketamine/diazepam, vs propofol, for mixture of propofol, alfentanil, and lidocaine
patients, S-209 transvaginal oocyte retrieval, S-176 for ophthalmic surgery under
vs piritramide, PCIA, S-202 low-dose, pre-administration, attenuation of MAC, S-12
nefopam, muscle relaxant effect, clinical and tourniquet pain, S-198 mixture of propofol, alfentanil, and lidocaine
experimental evaluation, S-193 methohexital, remifentanil and, for general for sedation, ophthalmic
Oxycontin, preemptive analgesia, laparoscopic anesthesia in Third World countries, S- procedures, obese vs normal weight
cholecystectomy, S-200 114 patients, S-258
S305 SUBJECT INDEX ANESTH ANALG
2003; 96; S-1–S-293
ropivacaine patients with chronic low back pain, S- fast-track anesthesia in off-pump
direct effects on sympathetic nerve activity, 215 cardiac surgery, S-47
rabbits, S-25 epidural patient-controlled epidural analgesia (PCEA)
long-term epidural infusion, pain management analgesia, clinical outcomes, adult postsurgical during labor and delivery, use of background
for pregnant patient with uterine patients, S-292 infusion, S-186
leiomyoma, S-210 analgesia, labor, response time and patient labor, levobupivacaine vs S-ropivacaine, S-184
S-ropivacaine, vs levobupivacaine, for satisfaction, S-180 relief of uterine artery embolization pain, S-211
parturient-controlled epidural labor analgesia, observational database for outcomes, third day post cesarean section pain, S-179
analgesia, S-184 pediatric patients, S-225 patient-controlled intravenous analgesia (PCIA),
time-dependent inhibition analgesia, postoperative, vs PCA morphine, morphine vs piritramide, S-202
mechanisms, S-250 ultra-fast-track anesthesia in off- patient-controlled sedation and analgesia (PCSA),
site of action, S-249 pump cardiac surgery, S-47 with remifentanil-propofol for shock
wound administration, effect on recovery after identification of cerebrospinal fluid, wave lithotripsy, S-11
major orthopedic surgery, S-205 prostaglandin D2 as marker, S-278 peribulbar block, cataract surgery, S-281
Anesthetics, volatile influence on intravenous induction with peripheral nerve block, determination of point of
binding to serum albumin, calorimetric propofol, S-291 needle insertion, S-282
measurements, S-246 suturing, reactivation of labor epidural preemptive analgesia
enflurane, vs propofol, effects in corrective surgery catheters for postpartum tubal long-acting oral medication, patients
of scoliosis with posterior ligation surgery, S-182 undergoing elective laparoscopic
instrumentation, S-63 time of block, station of presenting part vs cholecystectomy, S-197
halothane cervical dilatation as predictors of oral dextromethorphan premedication, effect
solubility, temperature dependence, S-247 cesarean delivery, S-187 on postoperative analgesic
vs isoflurane, effects of increased with and without opioids, patients undergoing consumption after dental surgery,
intraabdominal pressure on liver bowel resection, S-201 S-197
functions during laparoscopic with 0.25% bupivacaine, effects on rapid sequence induction, hypertensive patients, S-
cholecystectomy, S-125 neuroendocrine response to major 265
isoflurane abdominal surgery, S-290 regional
anesthetic preconditioning, S-15 epidural steroid injections, efficacy, patients with dexmedetomidine sedation during, S-13
impact of on intracellular calcium, arrhythmia, axial and radicular pain, S-277 elective cesarean section, partner anxiety, S-
and contractility, S-17 fascia iliaca block, postoperative analgesia, total 181
MAC, CPB-induced reduction, rats, S-35 knee arthroplasty, S-204 sedation with sevoflurane vs propofol,
positive pressure ventilation and, effect on femoral nerve block, analgesia, effect on outcomes orthopedic surgery, S-259
physiologic deadspace volume, after anterior cruciate ligament sedation
patients receiving general reconstruction, S-293 deep, dental treatment of intellectual disability,
anesthesia, S-44 general S-7
solubility, temperature dependence, S-247 composite EEG and FEMG signal, monitoring dexmedetomidine, during regional anesthesia,
vs halothane, effects of increased entropy, S-135 S-13
intraabdominal pressure on liver hypothermia during MRI scanning, children, S- dexmedetomidine, for awake carotid
functions during laparoscopic 224 endarterectomy, rationale and
cholecystectomy, S-125 modern anesthetic agents, Third World safety, S-166
pretreatment with, prevention of neutrophil-induced countries, S-114 effect of spinal anesthesia on processed EEG,
contractile dysfunction, isolated rat physiologic deadspace volume, effect of S-284
hearts, S-32 positive pressure ventilation and hypoxia and upper airway obstruction, S-275
sevoflurane isoflurane, S-44 ketamine/diazepam, vs propofol, for
anesthesia, recovery after oral midazolam recovery after, facilitation, BIS vs AEP transvaginal oocyte retrieval, S-176
premedication, effect of flumazenil, monitoring, S-129 mechanically ventilated critically ill patients,
modification by caudal analgesia, vs monitored anesthesia care, use of use of BIS monitoring, S-67
S-227 remifentanil, comparison of ophthalmic procedures, mixture of propofol,
anesthetic preconditioning, guinea pig hearts, medications in PACU, S-273 alfentanil, and lidocaine, obese vs
S-14, S-16 hypotensive anesthesia, reducing blood loss during normal weight patients, S-258
combined with BIS monitoring, comparison of bimaxillary osteotomy, S-62 PCSA with remifentanil-propofol for shock
anesthetic methods, S-65 interscalene block, safety and efficacy for outpatient wave lithotripsy, S-11
concentrations of 1% and 1.5%, BIS values, shoulder surgery, S-280 sevoflurane vs propofol, patients undergoing
lower segment cesarean section, S- laryngoscopy regional anesthesia for orthopedic
175 difficult, thyromental distance as predictor, S- surgery, S-259
MAC and Cp50, for insertion of ProSeal vs 83 somatic paravertebral block, efficacy for
classic LMA, S-267 effect of head position on Cormack scale postoperative pain relief, children
occupational exposure, assessment in exhaled grading, S-156 undergoing open appendectomy, S-226
breath, S-148 simulated grade III difficult, tracheal spinal
solubility, temperature dependence, S-247 intubation, fiberoptic scope vs chloroprocaine, dose-response effects, S-285
vs propofol, sedation, patients undergoing plastic bougie, S-43 effect on processed EEG, S-284
regional anesthesia for orthopedic simulated grade III difficult, tracheal systemic hypotension after, preventive effect of
surgery, S-259 intubation, single-use plastic vs blood volume increase by
Anesthetic techniques multiple-use gum elastic bougie, S- hypertonic saline administration, S-
axillary block, use of Pentagon pointed needle, S- 42 286
199 warning system to detect contact with upper target-controlled infusion, propofol
caudal analgesia, modification of effect of teeth, S-159 induction, influence of epidural anesthesia, S-
flumazenil on recovery from local anesthetic wound administration, effect on 291
sevoflurane anesthesia after oral recovery after major orthopedic surgery, measured concentration and simulation results,
midazolam premedication, S-227 S-205 S-126
cervical plexus block, superficial vs deep block for monitored anesthesia care, vs general anesthesia, total intravenous anesthesia, technique for wake-up
carotid endarterectomy, complication use of remifentanil, comparison of test, S-163
rate, S-279 medications in PACU, S-273 tumescent local anesthesia, S-283
closed-circuit anesthesia, teaching of, use of digital neuroaxial, for labor analgesia, enoxaparin therapy ultra-fast-track, off-pump cardiac surgery,
anesthesia machine, S-105 during pregnancy, S-178 postoperative epidural analgesia vs PCA
combined spinal-epidural, patient position during neuromuscular block morphine, S-47
induction, total knee arthroplasty, S-289 offset, abducting vs adducting laryngeal Anterior cruciate ligament reconstruction, see
continuous spinal anesthesia, elderly patients muscles, S-269 Surgery, knee
comparison of two different catheters, S-287 vecuronium-induced, reversal, effect of dosage Antibiotics, methicillin, -resistant Staphylococcus
hyperbaric bupivacaine 3mg plus fentanyl and timing of neostigmine aureus, general ICU, S-74
10µg for hemiarthroplasty, S-288 administration, S-271 Antioxidant therapy, effect on plasma endothelin-1 and
electroacupuncture, effects on pain relief and patient-controlled analgesia (PCA), morphine, vs thromboxane B2, effect of antioxidant
distribution of lymphocyte subsets, postoperative epidural analgesia, ultra- therapy after CPB, patients with congenital
heart disease, S-51
2003; 96; S-1–S-293
Anxiety, partner, elective cesarean section under hypotension Cesarean section, see Surgery
regional anesthesia, S-181 dexmedetomidine-related, following CABG, cGMP, see Heart, cyclic guanosine monophosphate
APACHE II, vs LODS, multidisciplinary ICU, S-73 characterization and management, Chaos theory, analysis of EEG, reflection of depth of
Apnea, see Complications S-255 anesthesia, S-244
Appendectomy, see Surgery systemic, after protamine administration, Charleston Comorbidity Score, as alternative to ASA
Aprotinin, see Coagulation; Pharmacokinetics association with in-hospital physical status classification, S-109
Arachnoiditis, see Complications mortality following CABG, S-57 Chloroprocaine, see Anesthetics, local
ASA Physical Status Classification systemic, after spinal anesthesia, preventive Choking, see Complications
alternatives, Charleston Comorbidity Score, S-109 effect of blood volume increase by Cholecystectomy, see Surgery
human errors by anesthesia providers, S-102 hypertonic saline administration, S- Cholinesterase, see Enzymes
Auditory evoked potential, see Monitoring 286 Chronic obstructive pulmonary disease, see
Awareness, see Complications Body weight, effects on respiratory system mechanics Complications
Axillary block, see Anesthetic techniques and oxygenation during laparoscopy, S-81 Chronic pain, see Pain
Bougies, see Equipment Cisatracurium, see Neuromuscular relaxants
Back pain, see Pain, chronic Bowel resection, see Surgery, abdominal Clonidine, see Pharmacology
Bariatric surgery, see Surgery Brain Closed circuit anesthesia, see Anesthetic techniques
Bcl-xL, effects on early mitochondrial changes in blood flow Coagulation
response to ischemia-like injury, S-174 regional, decreased in different regions of brain aprotinin
Beta-blockers, see Pharmacology by propofol and thiopental at equal following heparin doses used prior to CPB,
Billing system, see Economics drug effect, S-245 RapidPoint heparin management
Bispectral index, see Monitoring, velocity, cerebral artery, during ECT, effects of time, S-54
electroencephalography beta-blockers, S-168 reduction of interleukin-8 production and
Blood brainstem neuronal activities, effects of valerian, leukocyte infiltration after cerebral
carboxyhemoglobin, arteriovenous rats, S-232 ischemia-reperfusion, rabbits, S-
carboxyhemoglobin difference in cortical nNOS mRNA levels, increased, caused by 235
critical illness, S-78 hemodilutional anemia, S-26 effects of varying lead levels, S-154
circulating platelet-leukocyte associates, patients on intracranial pressure, during endoscopic third enoxaparin, therapy during pregnancy and
left ventricular assist devices, S-36 ventriculostomy, children, S-172 management of labor analgesia, S-178
lead levels ischemia protamine, administration
effects on oxygen hemoglobin dissociation, early mitochondrial changes, effects of Bcl-xL, hemodynamic changes associated with,
bovine blood, S-77 S-174 attenuation by diphenhydramine, S-
varying, interference with coagulation, S-154 focal, reactive hyperemia and infarct size 56
normothermic, delivery using dry heat warmer, following, effects of systemic hypotension after, association with in-
pediatric patients, S-61 dexmedetomidine, rats, S-165 hospital mortality following CABG,
perioperative blood salvage, incompletely filled intracellular acidosis, effects on steady-state S-57
Latham bowls, discontinuous vs rates of creatine kinase, rats, S-171 Cognitive dysfunction, see Complications
continuous processing systems, S-113 neuronal damage, dexamethasone-induced Colloids, see Fluid balance
potassium levels, donated blood, unpredictable aggravation, dopaminergic Combined spinal-epidural, see Anesthetic techniques
changes following warming, S-124 neurotransmission innervation and, Complications
red blood cells, increase by preoperative autologous rats, S-233 anemia, hemodilutional, as cause of transient
blood donation -reperfusion, interleukin-8 production and cerebral hypoxia and increased cortical
clinical parameters of impact, S-111 leukocyte infiltration after, effect of nNOS mRNA levels, S-26
physiologic basics of erythropoiesis, S-112 aprotinin, rabbits, S-235 apnea, detection during MAC, use of nasal
serum albumin, binding of volatile anesthetics, transient middle cerebral artery occlusion, capnography, S-147
calorimetric measurements, S-246 neuroprotective effect of xenon arachnoiditis, post-laminectomy, opioid sensitivity,
substitutes, hemoglobin-based oxygen carrier, administration, mice, S-167 rat model, S-191
lactate measurement in bovine blood mitochondrial respiration, differential effects of awareness, incidence using BIS monitoring, S-133
samples, S-76 bupivacaine, rats, S-170 cardiac, perioperative, risk, major vascular surgery
transfusion Bupivacaine, see Anesthetics, local performed within one month of CABG,
autologous, efficacy and cost-efficiency, Buprenorphine, see Pharmacology S-38
impact of rational medical cardiac arrest, during anesthesia for noncardiac
decision-making, S-110 Calcium surgery, S-37
autologous, role in recovery from hemorrhagic intracellular, impact of isoflurane during simulated choking, dental treatment of intellectual disability
shock, dogs, S-243 myocardial ischemia/reperfusion, S-17 under deep sedation, S-7
donated blood, unpredictable potassium mitochondrial Ca2+, effects of hypothermia during chronic obstructive pulmonary disease (COPD),
changes following warming, S-124 myocardial ischemia and reperfusion, severe, effects of patient positioning on
following cardiac surgery, impact of factor V guinea pig intact hearts, S-18 respiratory mechanics during
Leiden, S-58 Calorimetric measurements, see Measurement pneumoperitoneum, S-143
fresh frozen plasma, perioperative practice, techniques cognitive dysfunction, postoperative, short time
children, S-223 Cancer pain, see Pain survey, S-93
preoperative autologous blood donation, Capnography, see Monitoring congenital complete heart block, epicardial
increase in total RBC mass, clinical Carbon dioxide pacemaker placement, anesthetic
parameters of impact, S-111 levels in OR during gynecological laparoscopic implications, neonates, S-222
preoperative autologous blood donation, surgery, S-123 congenital diaphragmatic hernia, antenatally
increase in total RBC mass, ventilatory response, measurement, Read's diagnosed, perinatal management, S-
physiologic basics of rebreathing technique, S-29 177
erythropoiesis, S-112 Carboxyhemoglobin, see Blood delirium, postoperative, short time survey, S-93
Blood flow, see Brain; Lung Cardiac arrest, see Complications; Heart femoral pseudoaneurysm, as complication of
Blood loss Cardiac output, see Monitoring cardiac catheterization, incidence of
during bimaxillary osteotomy, reducing, S-62 Cardiopulmonary bypass, see Surgery cardiac death following anesthesia and
following cardiac surgery, impact of factor V Cardiopulmonary resuscitation, murine model for surgery, S-115
Leiden, S-58 postischemic inflammatory damage and gastroesophageal reflux, intraoperative, effects of
hemorrhagic shock, recovery from, role of naloxone functional recovery after, S-70 ranitidine, omeprazole, and placebo, S-
and autologous blood transfusion, dogs, Carotid endarterectomy, see Surgery 90
S-243 Cataract surgery, see Surgery, ophthalmic leiomyoma, uterine, pregnant patient, pain
Blood pressure Catheters, see Equipment management with long-term epidural
hemodynamic changes Celecoxib, see Premedication ropivacaine infusion, S-210
associated with protamine administration, Cerebral aneurysm clipping, see Surgery obesity
attenuation by diphenhydramine, S- Cerebrospinal fluid mixture of propofol, alfentanil, and lidocaine
56 appearance of rofecoxib in, following oral for sedation, ophthalmic
during endoscopic third ventriculostomy, administration, S-263 procedures, S-258
children, S-172 identification during epidural anesthesia, morbid, bariatric surgery, evolution of
hypertension, rapid sequence induction in prostaglandin D2 as marker, S-278 anesthetic management, S-91
hypertensive patients, S-265 Cervical plexus block, see Anesthetic techniques
2003; 96; S-1–S-293
morbid, effects on respiratory system Electronmicroscopy, evaluation of clot formation on Macintosh Video Laryngoscope, endotracheal
mechanics and oxygenation during thromboelastogram, S-155 intubation using, evaluation, S-157
laparoscopy, S-81 Emergency medical services, prehospital rapid needleless systems, accuracy in intravenous
Parkinson's disease, neuromuscular effects of sequence intubation, use by paramedics for administration of small volume drugs,
rocuronium, S-270 airway management, S-79 infants and children, S-152
postpolio syndrome, interventional pain Endoscopic third ventriculostomy, see Surgery needles
management, S-217 Endothelial cells insertion, direction, internal jugular vein
pulmonary injury, patients undergoing complex cytokine-induced cell death, delayed anesthetic puncture, S-221
spine surgery, S-75 preconditioning against, S-15 Pentagon pointed needle, use in axillary block,
sore throat, postoperative, prophylactic effect of human umbilical vein, cell volume and viability, S-199
dexamethasone, S-274 effects of hypertonic-hyperoncotic PAXpress, vs LMA, S-85
systemic inflammatory response syndrome, CPR solution, S-71 pneumotachograph, comparison of different
after cardiac arrest, S-70 Endotoxemia, ovine calibration methods, S-149
Computer model, left atrium, accurate simulation of arginine vasopressin-associated decrease in oxygen transport ventilator, continuous respiratory
pressure, flow, and volume, S-30 delivery, reversal by dopexamine, S-23 management after cardiac surgery, S-82
Computers, handheld, electronic self-administered arteriovenous carboxyhemoglobin difference in ventricular assist devices, Novacor vs HeartMate,
questionnaire vs paper version, S-3 critical illness, S-78 circulating platelet-leukocyte associates,
Congenital complete heart block, see Complications Endotracheal tube, see Equipment S-36
Congenital diaphragmatic hernia, see Complications Enflurane, see Anesthetics, volatile Ethnic differences, thyromental distance, S-84
Continuous spinal anesthesia, see Anesthetic Enoxaparin, see Coagulation Extubation
techniques Enzymes awake, endotracheal lidocaine with dispersion
COPD, see Complications, chronic obstructive cholinesterase, deficiency, identification of novel steam, S-162
pulmonary disease mutation, S-241 early, after cardiac surgery with CPB, S-49
Coronary artery bypass graft, see Surgery cyclooxygenase-2 (COX-2), spinal, influence of OR, simple and complicated aortic valve surgery, S-
Coronary revascularization, see Surgery postoperative pain, rats, S-190 48
Cyclooxygenase, see Enzymes Ephedrine, see Vasopressors Eye, intraocular pressure, effects of pneumoperitoneum
Cyclooxygenase inhibitors, see Pharmacology Epidural steroid injections, see Anesthetic techniques and position changes, S-146
Cytokines, see Inflammation Equipment Eye surgery, see Surgery, ophthalmic
airway sensor
Death, perioperative, unexpected, role of anesthetic fast-response, humidity measurement, S-119 Factor V Leiden, see Genetics
care, S-104 thermocouples, calibration in temperature- Fascia iliaca block, see Anesthetic techniques
Delirium, see Complications controlled water baths, S-120 Femoral nerve block, see Anesthetic techniques
Demographics, trends in trauma admissions, S-72 anesthesia machines Femoral pseudoaneurysm, see Complications
Dental surgery, see Surgery Datex-Ohmeda S/5™ ADU, gas usage monitor, Fentanyl, see Analgesics
Depression, effect of terrorism, S-218 facilitation of teaching of closed- Fluid balance
Dexamethasone, see Pharmacology circuit anesthesia, S-105 colloids, Hextend, prolongation of RapidPoint
Dexmedetomidine, see Anesthetics, intravenous Narcomed2B, absorber system vs Bain system, heparin management, S-54
Dextromethorphan, see Pharmacology humidity, S-118 hypertonic-hyperoncotic solution, effects on cell
Diazepam, see Pharmacology patient turned 180° away, manual ventilation volume and viability, human umbilical
Diphenhydramine, see Pharmacology by single operator, S-161 vein endothelial cells, S-71
Dispersion steam, see Equipment Biocore VarFlex flow transducer, flow resistance, S- saline, hypertonic
Dopexamine, see Pharmacology 145 blood volume increase, prevention of systemic
Dry heat warmer, see Equipment bougies hypotension after spinal anesthesia,
Dyes, indocyanine green, pulse dye densitometry, single-use plastic vs multiple-use gum elastic, S-286
assessment of hepatic function during tracheal intubation in simulated mechanism governing duration of extracellular
hepatic transplantation, S-151 grade III difficult laryngoscopy, S- volume expansion after infusion,
42 sheep, S-242
Economics vs fiberoptic scope, tracheal intubation in Fluid management, intraoperative, major gynecologic
billing system, pharmacy, Internet-based, use with simulated grade III difficult oncology procedures, facilitation using
automated anesthesia record, S-117 laryngoscopy, S-43 noninvasive cardiac output monitoring, S-
cost-efficiency, autologous transfusion, impact of cardiac output monitor, during aortic aneurysm 139
rational medical decision-making, S-110 repair, S-138 Flumazenil, see Pharmacology
ECT, see Electroconvulsive therapy catheters Frank-Starling mechanism, left atrium computer
Edrophonium, see Pharmacology comparison of techniques, continuous spinal model, S-30
Education anesthesia, elderly patients, S-287 Fresh frozen plasma, see Blood, transfusion
anesthesiology residency programs, personal digital epidural, insertion, prospective examination, S-
assistant use, survey, S-97 182 GABAA receptor, see Receptors
learning curve, variability in determination of point suturing, reactivation of labor epidural Gases, nonanesthetic, nitric oxide (NO), products, S-
of needle insertion in peripheral nerve catheters for postpartum tubal 100B protein and, plasma concentrations
blocks, S-282 ligation surgery, S-182 after cerebral aneurysm clipping, S-169
learning styles of anesthesiologists, S-96 dispersion steam, endotracheal lidocaine with, for Gastroesophageal reflux, see Complications
resident, teaching of closed-circuit anesthesia, use awake extubation, S-162 General anesthesia, see Anesthetic techniques
of digital anesthesia machine, S-105 dry heat warmer, delivery of normothermic blood Genetics
subspecialty anesthesia training and fluids, pediatric patients, S-61 factor V Leiden, protection against blood loss and
effect of additional (PGY-4) year, ten-year electronic pain control device, symptomatic transfusion following cardiac surgery, S-
review, S-94 treatment of chronic low back pain, S- 58
simple method for assessing knowledge 213 mutation, identification, cholinesterase deficiency,
growth, S-95 endotracheal tube, cuff, inflation, success rate of S-241
EEG, see Monitoring, electroencephalography blind nasotracheal intubation, S-158 polymorphisms, β2-adrenergic, uterine quiescence
Electroacupuncture, see Anesthetic techniques intubating laryngeal mask, success rates with and and, S-276
Electrocardiography, see Monitoring without fiberoptic guidance, S-86 Glucocorticoid, see Pharmacology
Electroconvulsive therapy (ECT) lactate analyzers, accuracy, bovine blood samples GP683, see Pharmacology, adenosine kinase inhibitors
cerebral artery blood flow velocity, effects of beta- containing hemoglobin-based oxygen Gynecological surgery, see Surgery
blockers, S-168 carrier, S-76
seizure activity after, effect of labetalol, S-8 laryngeal mask airway (LMA) Halothane, see Anesthetics, volatile
seizure duration gas diffusion through elliptical cuff, S-160 Heart
effect of remifentanil, S-9 insertion, conditions, improvement, nasal arrhythmia, impact of isoflurane during simulated
elongated, adjustment of anesthetic depth by administration of remifentanil, myocardial ischemia/reperfusion, S-17
BIS, S-131 children, S-219 cardiac arrest, murine model for postischemic
seizure time and awakening after, prediction, use of insertion, ProSeal vs classic LMA, sevoflurane inflammatory damage and functional
BIS, S-128 MAC and Cp50, S-160 recovery after CPR, S-70
Electroencephalography, see Monitoring insertion, use of remifentanil, S-266 cardiac hypertrophy, renal hypertension-induced,
Electronic pain control device, see Equipment vs PAXpress, S-85 cGMP phosphodiesterase inhibition and
2003; 96; S-1–S-293
uncoupling of β-adrenergic responses, natural killer cells, activity, metastatic development

S-34 and, effects of different anesthetic Kidney, renal tubular function during thoracotomy,
cardiomyocytes, rat, contractility during endothelin- agents, S-248 effect of fentanyl, S-264
1 and angiotensin II receptor activation, Indocyanine green, see Dyes Knee surgery, see Surgery
effect of propofol, S-33 Infection, Staphylococcus aureus, methicillin-resistant,
contractile dysfunction, neutrophil-induced, effect general ICU, S-74 Labetalol, see Pharmacology
of pretreatment with volatile Inflammation, cytokines Labor, see Pain
anesthetics, isolated rat hearts, S-32 -induced cell death, delayed anesthetic Lactate analyzers, see Equipment
cyclic guanosine monophosphate (cGMP), preconditioning of endothelium against, Lactate level, see Measurement techniques
phosphodiesterase inhibition and S-15 Laparoscopic surgery, see Surgery
uncoupling of β-adrenergic responses in interleukin-10/interleukin-6 ratio, oxidative stress Laryngeal mask airway, see Equipment
renal hypertension-induced cardiac and, inverse correlation, patients Laryngoscopy, see Anesthetic techniques
hypertrophy, S-34 undergoing CPB, S-52 Larynx, abducting vs adducting laryngeal muscles,
function, postoperative, following warm heart interleukin-8 production after cerebral ischemia- offset of neuromuscular block, S-269
surgery, intraoperative 15-F2t- reperfusion, effect of aprotinin, rabbits, Laterality policy, wrong-sided anesthetic and surgical
isoprostane as predictor, S-50 S-235 procedures, S-101
ischemia Inflammatory pain, see Pain Lead levels, see Blood
reperfusion, simulated, impact of isoflurane on Information systems, anesthesia records Leiomyoma, see Complications
intracellular calcium, arrhythmia, Internet-based pharmacy billing system, S-117 Leukocyte adhesion, role of urokinase receptor in
and contractility, S-17 secure access using Internet browser, S-116 myocardial ischemia and reperfusion, S-19
reperfusion injury, anesthetic preconditioning Intensive care units (ICUs) Levobupivacaine, see Anesthetics, local
triggered by ROS, guinea pig general, methicillin-resistant Staphylococcus Lidocaine, see Anesthetics, local
hearts, S-16 aureus, S-74 Liver, function
reperfusion injury, latency, effects of anesthetic multidisciplinary, comparison of APACHE II and assessment using indocyanine green pulse dye
preconditioning, S-14 LODS, S-73 densitometry during hepatic
reperfusion injury, mitochondrial Ca2+ practitioners, cognitive demands, consequences of transplantation, S-151
overload, attenuation by resource saturation and near-saturation, during laparoscopic cholecystectomy, effect of
hypothermia, guinea pig intact S-98 increased intraabdominal pressure,
hearts, S-18 Interactions, drug, edrophonium and neostigmine, S- halothane vs isoflurane, S-125
reperfusion injury, role of urokinase receptor, 240 Liver transplantation, see Surgery
S-19 Interleukins, see Inflammation, cytokines LMA, see Equipment, laryngeal mask airway
reperfusion injury, stunned myocardium, Internet Logistic Organ Dysfunction System (LODS), vs
cardioprotective effects of fentanyl, -based pharmacy billing system with automated APACHE II, multidisciplinary ICU, S-73
dogs, S-20 anesthesia record, S-117 Lung
left atrium, computer model, S-30 browser, secure access to anesthesia records and OR blood flow, noninvasive measurements by partial
left ventricular ejection time, stroke volume and, schedules, S-116 rebreathing, sources of error, computer
correlation between, in prone position Interscalene block, see Anesthetic techniques model study, S-141
using TEE, S-137 Intubating laryngeal mask, see Equipment pulmonary hypertension, acute, porcine model,
mitochondrial respiration, differential effects of Intubation effects of UK343-664, S-31
bupivacaine, rats, S-170 effect of head position on Cormack scale grading pulmonary vasculature, feline
rate during laryngoscopy, S-156 analysis of muscimol, S-228
during endoscopic third ventriculostomy, endobronchial, failure to diagnose by auscultation effects of norepinephrine, S-230
children, S-172 of bilateral breath sounds, children, S- Ma Huang vasopressor effects, mediation by
stress response to impending surgery, routine 220 α1B receptor, S-231
use of beta-blockers and, S-260 endotracheal responses to ephedrine, S-228
use of preoperative beta-blocker therapy, S-41 auscultation of bilateral breath sounds,
stroke volume, left ventricular ejection time and, children, S-220 MAC, see Potency, anesthetic
correlation between, in prone position evaluation using Macintosh Video Macintosh Video Laryngoscope, see Equipment
using TEE, S-137 Laryngoscope, S-157 Ma Huang, see Herbal medicine
ventricular fibrillation failed, continuous oxygen insufflation as additional Measurement techniques
decline of bupivacaine concentration, rabbits, tool, swine, S-80 calorimetric, binding of volatile anesthetics to
S-253 nasotracheal, blind, success rate, assessment of serum albumin, S-246
myocardial tissue hypoxia and acidosis during, endotracheal tube cuff inflation, S-158 humidity, fast-response airway sensor, S-119
effect of bupivacaine, S-21 rapid sequence, prehospital, use by paramedics for lactate level, bovine blood samples containing
Hemiarthroplasty, see Surgery airway management in medical hemoglobin-based oxygen carrier, S-76
Hemoglobin-based oxygen carrier, see Blood, emergencies, S-79 pulmonary blood flow, noninvasive measurement
substitutes reintubation, during first 24 hours following surgery by partial rebreathing, sources of error,
Herbal medicine and anesthesia, incidence and etiology, computer model study, S-141
Ma Huang, vasopressor effects, mediation by α1B S-87 pulse dye densitometry, indocyanine green,
receptor in pulmonary vascular bed, tracheal, simulated grade III difficult laryngoscopy assessment of hepatic function during
cats, S-231 fiberoptic scope vs plastic bougie, S-43 hepatic transplantation, S-151
valerian, effects on brainstem neuronal activities, single-use plastic vs multiple-use gum elastic Read's rebreathing technique, ventilatory response
rats, S-232 bougie, S-42 to CO2, S-29
Herniorrhaphy, see Surgery warning system to detect contact with upper teeth Sonoclot® analysis, neurosurgical patients, S-173
Hextend, see Fluid balance, colloids during laryngoscopy, S-159 spirometry, intraoperative, pulmonary changes in
Hormones, endocrine response during thoracotomy, In vitro fertilization, transvaginal oocyte retrieval, radical laparoscopic prostatectomy, S-
effect of fentanyl, S-264 propofol anesthesia vs ketamine/diazepam 92
Hospitals, trends in trauma admissions, S-72 sedation, S-176 thyromental distance
Human errors, by anesthesia providers, contributing Ion channels as predictor of difficult laryngoscopy, S-83
factors, S-102 cyclic nucleotide-gated channels, differential population, changes with ethnicity, S-84
Hydrodissection, tumescent local anesthesia, S-283 inhibition by local anesthetics, S-251 Memory, patient education, information load, S-100
Hypertension, see Blood pressure; Lung mechanically activated, in pain transduction, S-194 Meta-analysis, see Statistics
Hyperthermia, see Temperature Ischemia, see Brain; Heart; Spine Methicillin, see Antibiotics
Hypertonic-hyperoncotic solution, see Fluid balance Isoflurane, see Anesthetics, volatile Methohexital, see Anesthetics, intravenous
Hypotension, see Blood pressure 15-F2t-Isoprostane Midazolam, see Pharmacokinetics; Pharmacology;
Hypotensive anesthesia, see Anesthetic techniques intraoperative, as predictor of postoperative cardiac Premedication
Hypothermia, see Temperature function following warm heart surgery, Minimum alveolar concentration, see Potency,
Hypoxia, see Oxygen S-50 anesthetic
Hysterectomy, see Surgery, abdominal oxidative stress and interleukin-10/interleukin-6 Mitochondria
ratio, inverse correlation, patients ATP synthesis and ROS formation after ischemia,
Immune system, lymphocyte subsets undergoing CPB, S-52 effects of anesthetic preconditioning,
distribution, effects of electroacupuncture, patients guinea pig hearts, S-16
with chronic low back pain, S-215 Journals, see Publications Ca2+ overload during myocardial ischemia and
Jugular venous oxygen saturation, see Monitoring reperfusion, attenuation by
2003; 96; S-1–S-293
hypothermia, guinea pig intact hearts, S- neuromuscular, prototype monitor using Nitrous oxide, see Anesthetics, gases
18 phonomyography, S-136 Nociception, see Pain
early changes in response to ischemia-like injury, oxygen consumption Norepinephrine, see Vasopressors
effects of Bcl-xL, S-174 calibration of airway humidity sensor
mitochondrial respiration, differential effects of thermocouples, S-120 Obesity, see Complications
bupivacaine, rat brain and rat heart, S- fast-response airway opening humidity sensor, Occupational hazards, exposure to sevoflurane,
170 S-119 assessment in exhaled breath, S-148
Mivacurium, see Neuromuscular relaxants phonomyography, prototype neuromuscular Office-based surgery, see Surgery
Monitored anesthesia care, see Anesthetic techniques monitor using, S-136 Omeprazole, see Pharmacology
Monitoring platelet aggregation, CPB-induced defect, whole Operating room (OR)
auditory evoked potential (AEP) blood aggregometer vs Sonoclot® CO2 levels, during gynecological laparoscopic
A-line ARX index, vs BIS, during propofol- analyzer, S-55 surgery, S-123
fentanyl-N2O anesthesia, S-130 pulmonary, Biocore VarFlex flow transducer, flow extubation, simple and complicated aortic valve
effect on intraoperative drug usage and resistance, S-145 surgery, S-48
recovery after inpatient surgical RapidPoint heparin management time, prolongation schedules, secure access using Internet browser, S-
procedures, S-127 by hemodilution with colloid, S-54 116
vs BIS, facilitation of recovery after general regional cerebral oxygen saturation (rSO2), trauma patients presenting acutely to OR,
anesthesia, S-129 dissociation between rSO2 and SjO2, evaluation of BIS, S-134
vs BIS, recovery after ambulatory anesthesia, cardiovascular surgery with Ophthalmic surgery, see Surgery
S-5 hypothermic CPB, S-60 Opioids, epidural anesthesia with and without, patients
vs BIS, signal responses to inadequate thromboelastography undergoing bowel resection, S-201
anesthesia, S-132 electronmicroscopic evaluation of clot Osteotomy, see Surgery
capnography, nasal, patient safety during MAC, S- formation, S-155 Outcomes
147 study of effects of varying lead levels on adverse
cardiac output coagulation, S-154 cardiac, effects of chronic vs acute beta-
during aortic aneurysm repair, evaluation, S- transcranial Doppler ultrasonography, neurosurgical adrenoceptor blockade, S-261
138 patients with unfavorable outcome, S-68 selected risk factors and, relationship between,
measurement, accuracy of truCCOMS system, transesophageal echo-Doppler monitoring, patients undergoing thoracic,
S-140 correlation between stroke volume and otolaryngologic, orthopedic,
noninvasive, facilitation of intraoperative fluid left ventricular ejection time in prone urologic, and general surgeries, S-
management, major gynecologic position, S-137 108
oncology procedures, S-139 Morphine, see Analgesics after anterior cruciate ligament reconstruction,
cerebral oxygen metabolism, neurosurgical patients Muscimol, see Receptors, GABAA, agonists effect of femoral nerve block analgesia,
with unfavorable outcome, S-68 Muscle relaxants S-293
electrocardiography (ECG), novel sternal device vs effect of nefopam, clinical and experimental after outpatient inguinal herniorrhaphy,
Backpad ECG and standard three-lead evaluation, S-193 improvement with rofecoxib
ECG, S-150 randomized controlled trials, variability of premedication, S-2
electroencephalography (EEG), bispectral index exclusion criteria, S-89 clinical, with epidural analgesia, adult postsurgical
(BIS) TAAC3, peripheral muscarinic and nicotinic patients, S-292
adjustment of anesthetic depth, elongated receptor-mediated effects, rats, S-237 medium-term, following coronary
seizure duration in ECT, S-131 Music, hemispheric synchronization, effect on amount revascularization, CPB vs OP-CAB, S-
incidence of awareness using, S-133 of intraoperative analgesia required, S-257 46
influence of epidural anesthesia on intravenous Mutation, see Genetics prediction, ICUs, comparison of APACHE II and
induction with propofol, S-291 LODS, S-73
mechanically ventilated critically ill patients, Naloxone, see Pharmacology surgical, office surgery and ambulatory surgery
S-66 Natriuresis, as mechanism governing duration of centers, following implementation of
prediction of seizure time and awakening after extracellular volume expansion after office regulations, S-4
ECT, S-128 infusion of hypertonic saline, sheep, S-242 Oxycontin, see Analgesics
sedation in mechanically ventilated critically ill Natural killer cells, see Immune system, lymphocyte Oxygen
patients, S-66 subsets consumption
short surgical procedures using propofol, S-6 Needleless systems, see Equipment calibration of airway humidity sensor
trauma patients presenting acutely to OR, S- Needles, see Equipment thermocouples, S-120
134 Nefopam, see Analgesics fast-response airway opening humidity sensor,
use of sevoflurane, comparison of anesthetic Neostigmine, see Pharmacology S-119
methods, S-65 Nerves, vagal, blockade, effect on dead space delivery, arginine vasopressin-associated decrease
values at sevoflurane concentrations of 1% and ventilation, S-144 during ovine endotoxemia, reversal by
1.5%, lower segment cesarean Neuromuscular block, see Anesthetic techniques dopexamine, S-23
section, S-175 Neuromuscular relaxants diffusion through elliptical cuff of LMA, S-160
vs AEP cisatracurium, effect on survival of rat sympathetic hypoxia
facilitation of recovery after general neurons in vitro, S-239 cerebral, transient, caused by hemodilutional
anesthesia, S-129 mivacurium, effect on survival of rat sympathetic anemia, S-26
recovery after ambulatory anesthesia, S-5 neurons in vitro, S-239 effects on upper airway obstruction, S-275
signal responses to inadequate anesthesia, rocuronium human umbilical vein endothelial cells, S-71
S-132 -induced neuromuscular blockade, effects of myocardial tissue, during ventricular
vs A-line ARX index, during propofol- phenytoin, rat hemidiaphragm fibrillation, effect of bupivacaine,
fentanyl-N2O anesthesia, S-130 preparation, S-238 S-21
electroencephalography (EEG), chaotic analysis, neuromuscular effects, patients with regulation of α1a-adrenergic receptor gene
reflection of depth of anesthesia, S-244 Parkinson's disease, S-270 promoter, rats, S-22
electroencephalography (EEG), composite EEG and TAAC3, neuromuscular block by infusion, insufflation, continuous, as additional tool for failed
FEMG signal, monitoring entropy monkeys, S-236 intubation, swine, S-80
during general anesthesia, S-135 vecuronium, -induced neuromuscular blockade, oxygen hemoglobin dissociation, effects of lead,
electroencephalography (EEG), processed, PSA reversal, effect of dosage and timing of bovine blood, S-77
4000, effect of spinal anesthesia, S-284 neostigmine administration, S-271 Oxygenation, during laparoscopy, effects of weight and
jugular venous oxygen saturation (SjO2) Neurons, rat sympathetic neuronal cells, survival, mode of ventilation, S-81
dissociation between rSO2 and SjO2, effects of cisatracurium vs mivacurium, S-
cardiovascular surgery with 239 Pain
hypothermic CPB, S-60 Neutrophils axial, efficacy of epidural steroid injections, S-277
effect of slow rewarming during rewarming adhesion molecules, CD11b and CD18, expression, cancer, vs chronic nonmalignant pain, quality of
period, S-61 effect of midazolam, S-69 life, survey, S-212
magnetic resonance imaging (MRI), under general -induced contractile dysfunction, effect of chronic
anesthesia, children pretreatment with volatile anesthetics, back, in glucocorticoid-induced osteoporosis,
differences in tympanic and rectal temperature isolated rat hearts, S-32 production of pain relief by
changes, S-122 Nicotine, see Pharmacology pamidronate, S-214
incidence of hypothermia, S-224 Nitric oxide, see Gases, nonanesthetic
2003; 96; S-1–S-293
back, low, effects of electroacupuncture on propofol, measured concentration and simulation administration, effect of dosage and timing on
pain relief and distribution of results, S-126 reversal of vecuronium-induced
lymphocyte subsets, S-215 Pharmacology neuromuscular blockade, S-271
back, low, symptomatic treatment, noninvasive adenosine kinase inhibitors, GP683, effect on interactions with edrophonium, rat trachea, S-
electronic pain control device, S- hemodynamic and sympathetic outflow, 240
213 nerve-intact and baroreceptor- nicotine, as potential antiemetic, S-272
effect of terrorism, S-218 denervated rabbits, S-24 omeprazole, effects on intraoperative
nonmalignant, vs cancer pain, quality of life, beta-blockers gastroesophageal reflux, S-90
survey, S-212 chronic vs acute medication, effects on cardiac pamidronate, production of pain relief for chronic
inflammatory, clonidine and bupivacaine, spinally outcome, S-261 back pain in glucocorticoid-induced
mediated analgesic interaction, rats, S- effects on cerebral artery blood flow velocity osteoporosis, S-214
192 during ECT, S-168 phenytoin, effects on rocuronium-induced
labor, analgesia, neuroaxial anesthesia, enoxaparin preoperative use, heart rate and, S-41 neuromuscular blockade, rat
therapy during pregnancy, S-178 routine use, failure to blunt stress response to hemidiaphragm preparation, S-238
nociception, development of primate behavioral impending surgery, S-260 ranitidine, effects on intraoperative
nociceptive assay, S-188 buprenorphine, low dose, enhancement of spastic gastroesophageal reflux, S-90
phantom, continuous application of intrathecal paraparesis induced by intrathecal selegiline, effect on contractile and
morphine, S-216 morphine after non-injurious interval of phosphatidylinositol responses of rat
postoperative spinal ischemia, rats, S-234 trachea, S-28
acute, effect on range of motion after total knee clonidine sildenafil, analog, UK343-664, effects on porcine
arthroplasty, S-203 bupivacaine and, spinally mediated interaction, model of acute pulmonary hypertension,
appendectomy, efficacy of somatic acute thermally or inflammatory S-31
paravertebral block for pain relief, induced pain, rats, S-192 tropisetron, prevention of PONV, efficacy and
children, S-226 intrathecal, failure to improve postoperative safety, S-1
epidural analgesia, observational database for pain management after complex Phenytoin, see Pharmacology
outcomes, pediatric patients, S-225 spine surgery, S-206 Phonomyography, see Monitoring
influence on spinal COX-2, rats, S-190 cyclooxygenase-2 inhibitors, rofecoxib Phosphatidylinositol response, see Trachea
management after complex spine surgery, appearance in cerebrospinal fluid following Platelet aggregation, see Monitoring
failure of intrathecal clonidine to oral administration, S-263 Pneumoperitoneum, see Surgery, laparoscopic
improve, S-206 preemptive analgesia, patients undergoing Pneumotachograph, see Equipment
orthopedic surgery, effect of local anesthetic laparoscopic cholecystectomy, S- Polymorphisms, see Genetics
wound administration, S-205 200 PONV, see Vomiting, nausea and, postoperative
radical prostatectomy, analgesic effect of single premedication, outcome after outpatient Position
7.5 mg dose of IV morphine, S-208 inguinal herniorrhaphy, S-2 changes during pneumoperitoneum, effects on
role of heated and humidified intraperitoneal role in reducing non-incisional intraocular pressure, S-146
gases during laparoscopic Roux-en- postthoracotomy pain, S-196 during induction of combined spinal-epidural
y surgery, S-121 dexamethasone anesthesia, total knee arthroplasty, S-
thoracotomy, analgesic drug sensitivity in new -induced aggravation of ischemic neuronal 289
rat model, S-189 damage, dopaminergic effects on respiratory mechanics during
thoracotomy, non-incisional, reducing, role of neurotransmission innervation and, pneumoperitoneum, severe COPD
selective COX-2 inhibitors, S-196 relationship between, rats, S-233 patients, S-143
total abdominal hysterectomy, analgesic effect prophylactic effect on postoperative sore head, effect on Cormack scale grading during
of single 7.5 mg dose of IV throat, S-274 laryngoscopy, S-156
morphine, S-207 dextromethorphan, oral premedication, reduction of prone, correlation between stroke volume and left
uterine artery embolization, relief by PCEA postoperative analgesic consumption ventricular ejection time, S-137
with different mixtures, S-211 after dental surgery, S-197 Postanesthesia care unit (PACU), comparison of
radicular, efficacy of epidural steroid injections, S- diazepam, ketamine/diazepam, vs propofol, for medications following use of remifentanil
277 transvaginal oocyte retrieval, S-176 for monitored anesthesia care vs general
thermal, clonidine and bupivacaine, spinally diphenhydramine, attenuation of hemodynamic anesthesia, S-273
mediated analgesic interaction, rats, S- changes associated with protamine Postpolio syndrome, see Complications
192 administration, S-56 Potassium levels, see Blood
tourniquet, attenuation, pre-administration of low- dopexamine, reversal of arginine vasopressin- Potency, anesthetic, minimum alveolar concentration
dose ketamine, S-198 associated decrease in oxygen delivery (MAC)
transduction, mechanically activated ion channels, during ovine endotoxemia, S-23 isoflurane, CPB-induced reduction, rats, S-35
S-194 edrophonium, interactions with neostigmine, rat mixture of propofol, alfentanil, and lidocaine for
Pamidronate, see Pharmacology trachea, S-240 ophthalmic surgery, S-12
Parkinson's disease, see Complications flumazenil patient safety during, nasal capnography and, S-147
Patient-controlled analgesia, see Anesthetic techniques effect on recovery from sevoflurane anesthesia sevoflurane, insertion of ProSeal vs classic LMA,
Patient satisfaction, questionnaires after oral midazolam S-267
response time to initiate epidural analgesia for labor, premedication, modification by Preemptive analgesia, see Anesthetic techniques
S-180 caudal analgesia, S-227 Premedication
self-completed, electronic vs paper version, midazolam-flumazenil, vs propofol, scoliosis celecoxib, effect on recovery after outpatient
validation, S-3 surgery, S-164 surgery, S-195
PAXpress, see Equipment glucocorticoids midazolam, oral, recovery from sevoflurane after,
PCA, see Anesthetic techniques, patient-controlled -induced neuronal damage, dexamethasone- effect of flumazenil, modification by
analgesia induced aggravation, dopaminergic caudal analgesia, S-227
PCEA, see Anesthetic techniques, patient-controlled neurotransmission innervation and, rofecoxib, effect on outcome after outpatient
epidural analgesia rats, S-233 inguinal herniorrhaphy, S-2
PCIA, see Anesthetic techniques, patient-controlled -induced osteoporosis, chronic back pain, Preoperative autologous blood donation, see Blood,
intravenous anesthesia effect of pamidronate, S-233 transfusion
PCSA, see Anesthetic techniques, patient-controlled labetalol, effect on seizure activity after ECT, S-8 Preservative solutions, HTK vs UW, hemodynamic and
sedation and anlgesia midazolam metabolic changes during orthotopic liver
Peribulbar block, see Anesthetic techniques effect on expression of neutrophil adhesion transplantation, S-40
Peripheral nerve block, see Anesthetic techniques molecules CD11b and CD18 in Preterm delivery, β2-adrenergic polymorphisms and
Personal digital assistants, use in anesthesiology vitro, S-69 uterine quiescence, S-276
residency programs, survey, S-97 -flumazenil, vs propofol, scoliosis surgery, S- Prone position, see Position
Phantom pain, see Pain 164 Propofol, see Anesthetics, intravenous
Pharmacodynamics, comparative study, cardiotoxicity, sedative doses, effects on upper airway Prostaglandins
bupivacaine and levobupivacaine, S-253 obstruction, S-275 prostaglandin D2, as marker for identification of
Pharmacokinetics naloxone, role in recovery from hemorrhagic shock, cerebrospinal fluid during epidural
aprotinin, during CPB, small pediatric patients, S- dogs, S-243 anesthesia, S-278
53 neostigmine prostaglandin E1, dose-response study, radicular
midazolam, oral, effects of acetaminophen, S-262 blood flow velocity after lumbar
discectomy, S-39
2003; 96; S-1–S-293
Prostatectomy, see Surgery, urologic wrong-sided anesthetic and surgical procedures, S- aprotinin pharmacokinetics during, small
Protamine, see Coagulation 101 pediatric patients, S-53
Proteins, S-100B, NO products and, plasma Saline, see Fluid balance cardiac surgery with, early extubation, S-49
concentrations after cerebral aneurysm Scoliosis, see Surgery, spine hypothermic, cardiovascular surgery,
clipping, S-169 Sedation, see Anesthetic techniques dissociation between regional
Publications, journals, general anesthesiology, quality Seizure activity, ECT-induced cerebral and jugular venous oxygen
of study protocols and data analyses in duration saturation, S-60
randomized controlled trials, S-88 adjustment of anesthesia depth by BIS, S-131 -induced platelet aggregation defect,
Pulmonary injury, see Complications effect of remifentanil, S-9 monitoring, S-55
Pulse dye densitometry, see Measurement techniques effect of labetalol, S-8 oxidative stress and interleukin-10/interleukin-
time, prediction, use of BIS, S-128 6 ratio, inverse correlation, S-52
Quality assessment, study protocols and data analyses, Selegiline, see Pharmacology postoperative plasma endothelin-1 and
randomized controlled trials, general Sevoflurane, see Anesthetics, volatile thromboxane B2, effect of
anesthesiology journals, S-88 Shock, hemorrhagic, recovery from, role of naloxone antioxidant therapy, patients with
Quality of life, patients with cancer-related pain vs and autologous blood transfusion, dogs, S- congenital heart disease, S-51
chronic nonmalignant pain, survey, S-212 243 reduction of MAC of isoflurane, rats, S-35
Questionnaires, see Patient satisfaction Shoulder surgery, see Surgery rewarming period, effect of slow rewarming on
Sildenafil, see Pharmacology SjvO2, S-61
Radicular blood flow velocity, after lumbar Somatic paravertebral block, see Anesthetic vs OP-CAB, medium-term outcome following
discectomy, dose-response study of techniques coronary revascularization, S-46
prostaglandin E1, S-39 Sonoclot® analysis, see Measurement techniques cardiovascular, with hypothermic CPB, dissociation
Ranitidine, see Pharmacology Sore throat, see Complications between regional cerebral and jugular
Rapid sequence induction, see Anesthetic techniques Spinal anesthesia, see Anesthetic techniques venous oxygen saturation, S-60
Reading, effect on vigilance, clinical workload, and task Spinal cord, COX-2, influence of postoperative pain, carotid endarterectomy
distribution of anesthesia providers, S-99 rats, S-190 awake, dexmedetomidine sedation, S-166
Read's rebreathing technique, see Measurement Spine, ischemia, non-injurious interval, spastic superficial vs deep block, complication rate, S-
techniques paraparesis induced by intrathecal morphine 279
Receptors after, effect of low-dose buprenorphine, rats, cerebral aneurysm clipping, association between
α1a-adrenergic receptor gene promoter, cloning and S-234 plasma concentrations of NO products
characterization, rats, S-22 Spine surgery, see Surgery and S-100B protein, S-169
α2-adrenergic, agonists, dexmedetomidine, - Spirometry, see Measurement techniques cesarean section
induced vasoconstriction, Staphylococcus aureus, see Infection elective, under regional anesthesia, partner
intraoperative, S-256 Statistics, meta-analysis, tropisetron for prevention of anxiety, S-181
β-adrenergic PONV, S-1 levobupivacaine vs racemic bupivacaine,
blockade, chronic vs acute medication, effects Stochastic models intrathecal administration, S-185
on cardiac outcome, S-261 coding permutations, reduction prior to modeling of lower segment, BIS values at sevoflurane
responses, uncoupling in renal hypertension- dual procedure surgeries, S-106 concentrations of 1% and 1.5%, S-
induced cardiac hypertrophy, time estimates, factors affecting variability, dual 175
cGMP phosphodiesterase inhibition procedure surgeries, S-107 perinatal management of congenital
and, S-34 Stress response diaphragmatic hernia, S-177
β2-adrenergic, polymorphisms, uterine quiescence impending surgery, heart rate, routine use of beta- postoperative pain, third day, epidural PCA, S-
and, S-276 blockers and, S-260 179
angiotensin II, activation, rat cardiomyocytes, major abdominal surgery, neuroendocrine response, predictors, station of presenting part vs cervical
contractility, effect of propofol, S-33 effect of epidural anesthesia with 0.25% dilatation at time of epidural block,
cholinergic, effects of TAAC3, rats, S-237 bupivacaine, S-290 S-187
endothelin-1, activation, rat cardiomyocytes, Surgery cholecystectomy
contractility, effect of propofol, S-33 abdominal laparoscopic, liver functions during, effect of
GABAA, agonists, muscimol bowel resection, comparison of perioperative increased intraabdominal pressure,
analysis in pulmonary vascular bed, cats, S-229 anesthetic techniques, S-201 halothane vs isoflurane, S-125
effects on brainstem neuronal activities, rats, S- hysterectomy, total, analgesic effect of single laparoscopic, preemptive analgesia,
232 7.5 mg dose of IV morphine, S-207 comparison of Oxycontin,
G protein-coupled major, neuroendocrine response, effects of rofecoxib, and placebo, S-200
mechanisms of time-dependent inhibition by epidural anesthesia with 0.25% laparoscopic, vs laparotomic, effects of
local anesthetics, S-250 bupivacaine, S-290 perioperative pulmonary function,
site of action of time-dependent inhibition by aortic aneurysm repair, evaluation of cardiac output elderly patients, S-64
local anesthetics, S-249 monitor, S-138 laparotomic, vs laparoscopic, effects of
5-HT3, inhibition by local anesthetics, mechanisms aortic valve, simple and complicated, OR perioperative pulmonary function,
and sites of action, S-252 extubation, S-48 elderly patients, S-64
urokinase, role in myocardial ischemia and appendectomy, postoperative pain relief, efficacy of coronary artery bypass graft (CABG)
reperfusion, S-19 somatic paravertebral block, children, S- dexmedetomidine-related hypotension
Recovery profile 226 following, characterization and
after general anesthesia, facilitation by cerebral bariatric management, S-255
monitoring, AEP vs BIS, S-129 evolution of anesthetic management, S-91 in-hospital mortality following, systemic
after inpatient surgical procedures, effect of AEP intraoperative analgesic requirement, effect of hypotension after protamine
monitoring, S-127 listening to hemispheric administration, S-57
Regional anesthesia, see Anesthetic techniques synchronization, S-257 major vascular surgery performed within one
Regional cerebral oxygen saturation, see Monitoring cardiac month, risk of perioperative cardiac
Remifentanil, see Analgesics; Anesthetics, intravenous blood loss and transfusion following, impact of complications, S-38
Respiratory system, mechanics factor V Leiden, S-58 off-pump vs on-pump, postoperative
during laparoscopy, effects of weight and mode of continuous respiratory management with hyperthermia, S-45
ventilation, S-81 transport ventilator, S-82 coronary revascularization, CPB vs OP-CAB,
during pneumoperitoneum, effects of patient elevated plasma concentrations of mature form medium-term outcome, S-46
positioning, severe COPD patients, S- of adrenomedullin during, dental, postoperative analgesic consumption, effect
143 hepatosplanchnic hypoperfusion of oral dextromethorphan
Rocuronium, see Neuromuscular relaxants and, S-59 premedication, S-197
Rofecoxib, see Pharmacology, cyclooxygenase off-pump, ultra-fast-track anesthesia, dual procedures
inhibitors postoperative epidural analgesia vs reduction of coding permutations prior to
Ropivacaine, see Anesthetics, local PCA morphine, S-47 modeling, S-106
warm, postoperative cardiac function, time estimates, factors affecting variability, S-
Safety, patient intraoperative 15-F2t-isoprostane as 107
during MAC, nasal capnography and, S-147 predictor, S-50 endoscopic third ventriculostomy, cardiovascular
housestaff and medical student attitudes toward with CPB, early extubation, S-49 changes during, children, S-172
adverse medical events, S-103 cardiopulmonary bypass (CPB) epicardial pacemaker placement, neonates with
congenital complete heart block, S-222
2003; 96; S-1–S-293
femoral pseudoaneurysm, cardiac mortality office-based, outcomes following implementation core, role of heated and humidified intraperitoneal
gynecological of office regulations, S-4 gases during laparoscopic Roux-en-y
efficacy of remifentanil, ambulatory patients, ophthalmic surgery, S-121
S-10 cataract, peribulbar block, S-281 dependence, solubility of volatile anesthetics, S-247
laparoscopic, CO2 levels in OR during, S-123 mixture of propofol, alfentanil, and lidocaine, hyperthermia, postoperative, following off-pump vs
laparoscopic, gas composition of regional block under MAC, S-12 on-pump CABG, S-45
pneumoperitoneum during, S-142 mixture of propofol, alfentanil, and lidocaine, hypothermia
oncology procedures, facilitation of sedation, obese vs normal weight during MRI scanning under general anesthesia,
intraoperative fluid management patients, S-258 children, S-224
with noninvasive cardiac output orthopedic effects on mitochondrial Ca2+ during
monitoring, S-139 major, effect of local anesthetic wound myocardial ischemia and
oocyte retrieval, transvaginal, propofol administration on recovery, S-205 reperfusion, guinea pig intact
anesthesia vs ketamine/diazepam regional anesthesia, sedation with sevoflurane hearts, S-18
sedation, S-176 vs propofol, S-259 warming
total abdominal hysterectomy, analgesic effect relationship between selected risk factors and dry heat warmer, delivery of normothermic
of single 7.5 mg dose of IV adverse outcomes, S-108 blood and fluids, pediatric patients,
morphine, S-207 osteotomy, bimaxillary, reducing blood loss during, S-153
tubal ligation, postpartum, reactivation of labor S-62 slow rewarming rate, improvement of SjvO2
epidural catheters, success rate, otolaryngologic, relationship between selected risk during rewarming period, S-61
effect of suturing, S-183 factors and adverse outcomes, S-108 unpredictable changes in donated blood
uterine artery embolization, pain relief by repair of femoral pseudoaneurysm, incidence of following, S-124
PCEA with different mixtures, S- cardiac death following, patients with Terrorism, effect on chronic pain and depression, S-218
211 prior percutaneous transluminal Thermal pain, see Pain
hemiarthroplasty, continuous spinal anesthesia, coronary angioplasty and/or stent Thiopental, see Anesthetics, intravenous
hyperbaric bupivacaine 3mg plus insertion, S-115 Thoracotomy, see Surgery
fentanyl 10µg, elderly patients, S-288 shoulder, interscalene block, safety and efficacy, S- Thromboelastography, see Monitoring
herniorrhaphy, inguinal, outpatient, outcome, effect 280 Thyromental distance, see Measurement techniques
of rofecoxib premedication, S-2 spine Time estimates, dual procedure surgeries, factors
knee adhesive lumbar arachnoiditis, opioid affecting variability, S-107
anterior cruciate ligament reconstruction, sensitivity, rat model, S-191 Total knee arthroplasty, see Surgery, knee
outcomes, effect of femoral nerve complex, failure of intrathecal clonidine to Toxicity, cardiotoxicity, comparative pharmacodynamic
block analgesia, S-293 improve postoperative pain study, bupivacaine and levobupivacaine, S-
total knee arthroplasty, effect of acute management, S-206 253
postoperative pain on range of complex, patients undergoing, pulmonary Trachea
motion at time of discharge, S-203 injury, S-75 contractility, effect of selegiline, rats, S-28
total knee arthroplasty, fascia iliaca block for scoliosis, midazolam-flumazenil vs propofol interactions of edrophonium with neostigmine, rats,
postoperative analgesia, S-204 anesthesia, S-164 S-240
total knee arthroplasty, patient position during scoliosis, total intravenous anesthesia, phosphatidylinositol response, effect of selegiline,
induction of combined spinal- technique for wake-up test, S-163 rats, S-28
epidural anesthesia, S-289 scoliosis, with posterior instrumentation, Transcranial Doppler ultrasonography, see
laparoscopic propofol vs enflurane, S-63 Monitoring
cholecystectomy, effects of perioperative thoracic, relationship between selected risk factors Transesophageal echo-Doppler monitoring, see
pulmonary function, elderly and adverse outcomes, S-108 Monitoring
patients, S-64 thoracotomy Transfusion, see Blood
cholecystectomy, liver functions during, effect postoperative pain, analgesic drug sensitivity in Transport ventilator, see Equipment
of increased intraabdominal new rat model, S-189 Trauma
pressure, halothane vs isoflurane, postoperative pain, non-incisional, reducing, admissions, trends, S-72
S-125 role of selective COX-2 inhibitors, patients presenting acutely to OR, evaluation of
cholecystectomy, preemptive analgesia, S-196 BIS, S-134
comparison of Oxycontin, renal tubular function and endocrine response, Tropisetron, see Pharmacology
rofecoxib, and placebo, S-200 effect of fentanyl, S-264 Tubal ligation, see Surgery, gynecological
gynecological, CO2 levels in OR during, S-123 urologic Tumescent local anesthesia, see Anesthetic techniques
gynecological, gas composition of prostatectomy, radical, analgesic effect of
pneumoperitoneum during, S-142 single 7.5 mg dose of IV morphine, UK343-664, see Pharmacology, sildenafil
pneumoperitoneum, effects on intraocular S-208 Urokinase receptor, see Receptors
pressure, S-146 prostatectomy, radical, laparoscopic, Urologic surgery, see Surgery
radical prostatectomy, pulmonary changes pulmonary changes using Uterine artery embolization, see Surgery,
using intraoperative spirometry, S- intraoperative spirometry, S-92 gynecological
92 relationship between selected risk factors and
respiratory system mechanics and oxygenation, adverse outcomes, S-108 Vagal nerve, see Nerves
effects of weight and mode of vascular, major, performed within one month of Valerian, see Herbal medicine
ventilation, S-81 CABG, risk of perioperative cardiac Vasoconstriction, dexmedetomidine-induced,
Roux-en-y procedures, role of heated and complications, S-38 intraoperative, S256
humidified intraperitoneal gases, S- Sympathetic nervous system Vasoconstrictors, endothelin-1 and thromboxane B2,
121 adrenomedullin, mature form, elevated plasma after CPB, effect of antioxidant therapy,
liver transplantation concentrations during cardiac surgery, patients with congenital heart disease, S-51
assessment of hepatic function using hepatosplanchnic hypoperfusion and, S- Vasopressors
indocyanine green pulse dye 59 ephedrine, pulmonary vascular responses, cats,
densitometry, S-151 renal sympathetic nerve activity S228
orthotopic, hemodynamic and metabolic direct effects of ropivacaine and bupivacaine, norepinephrine, effects in pulmonary vascular bed,
changes, HTK vs UW preservative rabbits, S-25 cats, S230
solution, S-40 effect of GP683, nerve-intact and baroreceptor- Vecuronium, see Neuromuscular relaxants
lumbar discectomy, radicular blood flow velocity, denervated rabbits, S-24 Veins, internal jugular vein, puncture, direction of
dose-response study of prostaglandin Systemic inflammatory response syndrome, see needle insertion, S221
E1, S-39 Complications Ventilation
neurosurgery dead space, effect of vagal nerve blockade, S-144
cerebral oxygen metabolism and transcranial TAAC3, see Muscle relaxants; Neuromuscular relaxants manual, patient turned 180° away from anesthesia
Doppler ultrasonography Target-controlled infusion, see Anesthetic techniques machine, S-161
monitoring, comatose patients with Temperature mechanical
unfavorable outcome, S-68 changes, tympanic and rectal, differences, after BIS monitoring, critically ill patients, S-66
Sonoclot® analysis, S-173 MRI of brain under general anesthesia, flow resistance of Biocore VarFlex flow
noncardiac, anesthesia for, cardiac arrest during, S- children, S-122 transducer, S-145
37 sedation in critically ill patients, use of BIS
monitoring, S-67
2003; 96; S-1–S-293
mode, effects on respiratory system mechanics and

oxygenation during laparoscopy, S81
positive pressure, isoflurane and, effect on
physiologic deadspace volume, patients
receiving general anesthesia, S44
response to CO2, measurement, Read's rebreathing
technique, S29
transport ventilator, continuous respiratory
management after cardiac surgery, S82
transtracheal continuous oxygen insufflation, vs
transtracheal jet ventilation, as tool for
failed intubation, swine, S80
transtracheal jet ventilation, vs transtracheal
continuous oxygen insufflation, as tool
for failed intubation, swine, S80
Ventricular assist devices, see Equipment
Ventricular fibrillation, see Heart
Vomiting, nausea and, postoperative (PONV)
nicotine as potential antiemetic, S272
prevention, tropisetron, efficacy and safety, S-1
Warming, see Temperature
Xenon, see Anesthetics, gases

2003; 96; S-1–S-293

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ANESTHESIA

This Supplement will Appear On-Line Only

IARS SCA SPA SAMBA ISAP STA

©2003 by the International Anesthesia Research Society

NON-MEMBER SUBSCRIPTION RENEWALS should be for-

Critical Care and Trauma

Pain – Basic Sciences Pharmacology - Basic Science

administered for premedication prior to ambulatory surgery. Rofecoxib

with local anesthetic-based anesthesia techniques were randomly

optic probe that contains sensors to measure PmO2, pH and temperature

Economics; Education &

AUTHORS: I. A. Hilmi1, R. Abdullah1, R. Nicolau-Raducu1, A. Table 1: Study Group Data

Australia, 4Sophus Medical, Copenhagen, Denmark, 5University of Chicago, 1 65 M

INTRODUCTION: Bicore CP-100 monitor is using in many clinical

INTRODUCTION: Bcl-xL is a member of the Bcl-2 family and blocks

AUTHORS: H. A. Waibel1, S. Petrich2, T. Rinne1, B. A. Hall3, D. H. means ± SD Group 1 Group 2

Station vs C.S. rate

Pain - Basic Science

TAAC3 is an ultra-short and ultra-fast-acting non-depolarizing

AUTHORS: R. Michael1, M. M. Sabry2, K. Govindan1, A. R. Abadir1

INTRODUCTION: Local anesthetics (LA) were shown to inhibit the

Finegold H, Ohara C, Ramananathan S, Goldberg M, see Khaleghi B NICOTINIC RECEPTORS-MEDIATED

POSTANESTHESIA CARE UNIT PROSTATECTOMY USING Mannes AJ, see Polomano RC

CONGENITAL DIAPHRAGMATIC HERNIA: MODEL OF ACUTE PULMONARY Walsh F, see Ghori K

THROMBOXANE B2 AFTER CARDIAC SURGERY AND

Abdominal surgery, see Surgery piritramide, vs morphine, PCIA, S-202 propofol

uncoupling of β-adrenergic responses, natural killer cells, activity, metastatic development

mode, effects on respiratory system mechanics and

Warming, see Temperature

Xenon, see Anesthetics, gases

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